Nutritional status, the development and persistence of malnutrition and dietary intake in oesophago-gastric cancer: a longitudinal cohort study

Clinical significance of preoperative nutritional status in elderly gastric cancer patients undergoing radical gastrectomy: A single-center retrospective study

BACKGROUND

The population of elderly patients with gastric cancer is increasing, which is a major public health issue in China. Malnutrition is one of the greatest risk factors for adverse clinical outcomes in elderly patients with gastric cancer.

AIM

To investigate the preoperative nutritional status and its association with delayed discharge of elderly gastric cancer patients following radical gastrectomy.

METHODS

A total of 783 patients aged 65 years and older harboring gastric adenocarcinoma and following radical gastrectomy were retrospectively analyzed from the prospectively collected database of Zhongshan Hospital of Fudan University between January 2018 and May 2020.

RESULTS

The overall rate of malnutrition was 31.8%. The incidence of postoperative complications was significantly higher in the malnourished group compared to the well-nourished group (P < 0.001). Nutritional characteristics in the malnourished group, including body mass index, prognostic nutritional index (PNI), albumin, prealbumin, and hemoglobin, were all significantly lower than those in the well-nourished group. The percentage of patients who received postoperative total nutrient admixture was lower in the malnourished group compared to the well-nourished group (22.1% vs 33.5%, P = 0.001). Age ≥ 70 years (HR = 1.216, 95%CI: 1.048-1.411), PNI < 44.5 (HR = 1.792, 95%CI: 1.058-3.032), operation time ≥ 160 minutes (HR = 1.431, 95%CI: 1.237-1.656), and postoperative complications grade III or higher (HR = 2.191, 95%CI: 1.604-2.991) were all recognized as independent risk factors associated with delayed discharge.

CONCLUSION

Malnutrition is relatively common in elderly patients undergoing gastrectomy. Low PNI is an independent risk factor associated with delay discharge. More strategies are needed to improve the clinical outcome of these patients.

Factors influencing health-related quality of life in patients with bladder or kidney cancer: a prospective cohort study of the impact of nutritional status and frailty phenotype

PURPOSE

This study aimed to investigate the impact of nutritional status and frailty phenotype and the predictors of temporal changes on health-related quality of life (HRQoL) of patients with bladder or kidney cancer.

METHODS

Frailty phenotype, Patient-Generated Subjective Global Assessment, and Quality-of-life questionnaire Core-30 were applied twice to patients diagnosed with bladder or kidney cancer. Patients also completed a sociodemographic questionnaire, and clinical data were collected from records.

RESULTS

Sixty-two individuals completed the study, mostly male, with a mean age of 62.5 (± 11.4) years. The median time of follow-up was 14.5 months. Role functioning, emotional functioning, and fatigue improved over time (p < 0.05). The factors that negatively affected the long-term quality of life summary score were being female, malnourished, pre-frail and frail, cancer treatment, performance status, and lower income. Using the multivariate model, being malnourished (β =  - 7.25; 95% CI, - 10.78 to - 3.71; p < 0.001), frail (β =  - 7.25; 95% CI, - 13.39 to - 1.11; p = 0.021), and each one-point increase in performance status (β =  - 6.9; 95% CI, - 9.54 to - 4.26; p < 0.001), were the ones that most negatively impacted the HRQoL between the two assessments.

CONCLUSION

This study confirmed that frailty, nutritional status, and performance status are the main predictors of HRQoL of patients with bladder or kidney cancer over time.

IMPLICATIONS FOR CANCER SURVIVORS

These findings may be the first step towards highlighting the importance of preventing malnutrition and frailty, in favor of a better long-term QoL for cancer patients.

Severe reflux, malnutrition and health-related quality of life after oesophageal cancer surgery: A prospective nationwide cohort study

INTRODUCTION

While most survivors of oesophageal cancer suffer from multiple symptoms, studies on combined symptom burden are scarce, particularly when looking at long-term outcomes. Therefore, we aimed to investigate the association between gastro-oesophageal reflux and health-related quality of life in malnourished survivors during the first years after oesophagectomy for cancer.

MATERIALS AND METHODS

This nationwide prospective cohort study included all Swedish patients who underwent curatively intended oesophagectomy for oesophageal cancer between 2013 and 2020 with 3-year follow-up. Linear mixed effect models were used to analyse the associations between reflux symptoms, malnutrition and HRQL at 1-, 2- and 3 years post-surgery and were presented with mean score difference (MSD) and 95 % confidence intervals (CI).

RESULTS

Among 406 included individuals, malnourished survivors with severe reflux reported more problems with nausea/vomiting (MSD 16.3, 95 % CI: 11.4 to 21.3), pain (MSD 16.5, 95 % CI: 10.2 to 22.8), body image (MSD 12.3, 95 % CI: 5.6 to 19.0), eating restrictions (MSD 11.3, 95 % CI: 6.1 to 16.5), swallowing saliva (MSD 10.0, 95 % CI: 5.2 to 14.8), dry mouth (MSD 10.5, 95 % CI: 2.4 to 18.7), and taste (MSD 14.1, 95 % CI: 7.1 to 21.0) compared to malnourished survivors with no reflux. Nausea/vomiting, financial difficulties, body image, and cognitive function were consistently worse for malnourished individuals with reflux throughout the 3 years.

CONCLUSIONS

The study suggests that gastro-oesophageal reflux negatively influences health-related quality of life in malnourished oesophageal cancer survivors. Nausea and/or vomiting were consistently worse for malnourished individuals with reflux independent of time point.

Clinical Effect of Tumor-Specific Total Nutrients in Patients with Adjuvant Chemotherapy After Radical Gastric Cancer Resection: A Randomized Controlled Trial

BACKGROUND

In this study, we combined adjuvant chemotherapy after radical gastric cancer resection with tumor-specific total nutrient therapy to analyze how it affects the nutritional state and immune function of the patient.

METHOD

We collected data from 106 patients having undergone adjuvant chemotherapy after radical gastric cancer resection between January 2020 and December 2021. We divided the patients into experimental and control groups (with 53 cases in each group) through single-blinded simple randomization using a random number table and the sealed envelope system. The control group received chemotherapy and the regular nutritional diet at the same time while the experimental group received tumor-specific total nutrients based on the control group. We analyzed the index results for the physical examination, nutritional status, and immune function of the patients in both groups recorded before and after one chemotherapeutic cycle.

RESULTS

The control and experimental group compositions were as follows: 58.5% and 52.8% males with a mean age ± standard deviation of 54.36 ± 12.68 and 55.15 ± 12.32 years, respectively. After one chemotherapeutic cycle and the nutritional intervention, the experimental group displayed better physical examination indicators than the control group concerning the weight (55.8 ± 5.41 vs. 54.8 ± 6.94, p = 0.621), body fat mass (13.3 ± 0.88 vs. 13.1 ± 0.91, p = 0.253), upper arm circumference (21.9 ± 0.94 vs. 21.2 ± 1.23 cm, p = 0.001), triceps skinfold thickness (15.1 ± 1.36 vs. 14.3 ± 1.62 cm, p = 0.007), and grip strength (23.0 ± 1.30 vs. 22.3 ± 1.33, p = 0.007). In addition, the experimental group yielded better nutritional-status indicators than the control, including albumin (35.2 ± 1.60 vs. 33.7 ± 1.44 g/L, p = 0.001), hemoglobin (115.7 ± 9.28 vs. 111.5 ± 10.56 g/L, p = 0.032), total protein (63.7 ± 5.85 vs. 60.5 ± 5.27 g/L, p = 0.004), transferrin (2.5 ± 0.53 vs. 2.2 ± 0.58 g/L, p = 0.007), and immune-function indicators CD4+ (32.8 ± 4.82 vs. 28.8 ± 3.76, p = 0.001), CD8+ (34.1 ± 3.36 vs. 37.2 ± 3.85, p = 0.001), CD4/CD8 (1.0 ± 0.28 vs. 0.8 ± 0.34, p = 0.001), IgA (2.7 ± 1.43 vs. 4.1 ± 1.47, p = 0.001), and IgG (8.8 ± 1.74 vs. 10.9 ± 1.28, p = 0.001).

CONCLUSION

Combined tumor-specific total nutrient and adjuvant chemotherapy application after radical gastric cancer surgery effectively improves the nutritional state and immune function of the patients and could be applied in clinical practice.

The effectiveness of prehabilitation interventions on biopsychosocial and service outcomes pre and post upper gastrointestinal surgery: a systematic review

PURPOSE

This review synthesised the evidence for the effect of prehabilitation interventions on biopsychosocial and service outcomes.

MATERIALS AND METHODS

A systematic review was conducted. 10 databases were searched to December 2023. Prospective experimental studies exploring prehabilitation interventions in adults undergoing upper gastrointestinal surgery were included. Prehabilitation was any preoperative intervention to improve physical or psychological outcomes. Included studies required a comparator group or alternative preoperative intervention as well as baseline, presurgical and postoperative assessment points. Study quality was assessed using the Cochrane risk of bias tool (v.2). Data synthesis was narrative (SWiM guidance).

RESULTS

6028 studies were screened, with 25 studies included. Prehabilitation interventions were: inspiratory muscle training (five studies n = 450); exercise (nine studies n = 683); psychological (one study n = 400); and nutritional (ten studies n = 487). High quality studies showed preoperative improvements in impairments directly targeted by the interventions. Generally, these did not translate into functional or postoperative improvements, but multimodal interventions were more promising.

CONCLUSION

Current evidence supports prehabilitation as safe to preserve or improve preoperative function. Heterogeneity in outcomes and variable study quality means definitive conclusions regarding interventions are not yet possible, limiting implementation. Agreement of clinical outcomes and cost effectiveness evaluation is required.

Enhancing Nutrition Support for Esophageal Cancer Patients: Understanding Factors Influencing Feeding Tube Utilization

Objective: We sought to identify factors that can predict esophageal cancer (EC) patients at high risk of requiring feeding tube insertion. Methods: A retrospective cohort review was conducted, including all patients diagnosed with EC at our cancer center from 2013 to 2018. Multivariate logistic regression was performed comparing the group that required a reactive feeding tube insertion to those who did not require any feeding tube insertion to identify risk factors. Results: A total of 350 patients were included in the study, and 132/350 (38%) patients received a feeding tube. 50 out of 132 (38%) patients had feeding tube inserted reactively. Severe dysphagia (OR 19.9, p < 0.001) at diagnosis and decision to undergo chemotherapy (OR 2.8, p = 0.008) appeared to be predictors for reactive feeding tube insertion. The reactive insertion group had a 7% higher rate of complications relating to feeding tube. Conclusion: Severe dysphagia at diagnosis and undergoing chemotherapy were identified as risk factors for requiring a feeding tube. Ultimately, the aim is to create a predictive tool that utilizes these risks factors to accurate identify high-risk patients who may benefit from prophylactic feeding tube insertion.

High prognostic nutritional index could be associated with improved survival in patients with brain metastases: a retrospective observational study

BACKGROUND

Prognostic nutritional index (PNI) is an indicator of immunonutritional status. The present study aimed to evaluate the association between PNI and overall survival in patients with brain metastases.

METHODS

A total of 257 patients with histologically confirmed brain metastasis who underwent surgery at our center between April 2011 and April 2021 were investigated retrospectively.Demographic, clinical, and radiologic data of all cases were extracted. Patients were divided into the low PNI group(PNI <45) (malnutrition status) and the high PNI group (PNI ≥45)(normal nutritional status). Survival analyses were performed using the Kaplan-Meier method and compared using the log-rank test. Univariate and multivariate analyses were performed using the Cox proportional hazards method.

RESULTS

From the 257 cases of brain metastases, there were 148 (57.6%) males and 109 (42.4%) females. The mean age was 57.02 ± 8.7. The median overall survival was 13 months. The results of the multivariate Cox regression analyses showed primary cancer site (HR 2.196, 95% CI 1.988-6.52605, P = 0.000), the number of metastases (HR 1.829, 95% CI 1.380-2.872, P = 0.037), extracranial involvement (HR 2.186, 95% CI 1.213-4.171, P = 0.026), adjuvant radiotherapy (HR 2.823, 95% CI 1.187-5.415, P = 0.017) and PNI (HR 1.961, 95% CI 1.168-3.515, P = 0.021) as the independent predictors of overall survival in patients with brain metastases.

CONCLUSION

Our results suggest that PNI could be associated with survival in patients with brain metastases. Patients with a lower PNI had a significantly worse outcome in comparison with those with a higher PNI. Evaluation of PNI may provide additional prognostic information in patients with brain metastases.

Prognostic significance of the novel nutrition-inflammation marker of lymphocyte-C-reactive protein ratio in patients with nasopharyngeal carcinoma receiving concurrent chemoradiotherapy

Background

Recent studies indicate that the novel lymphocyte-C-reactive protein ratio (LCR) is strongly associated with the survival of various tumors, but its prognostic value in nasopharyngeal carcinoma (NPC) is understudied. This study aimed to explore the relationship between LCR and overall survival (OS) in NPC and develop a predictive model.

Methods

A total of 841 NPC patients who received concurrent chemoradiotherapy (CCRT) between January 2010 and December 2014 were retrospectively enrolled and randomly divided into a training cohort (n = 589) and a validation cohort (n = 252), and 122 patients between January 2015 and March 2015 were included as an additional validation cohort. Univariate and multivariate Cox analyses were performed to identify variables associated with OS and construct a predictive nomogram. The predictive accuracy of the nomogram was evaluated and independently validated.

Results

The LCR score differentiated NPC patients into two groups with distinct prognoses (HR = 0.53; 95% CI: 0.32-0.89, P = 0.014). Multivariate analysis showed that age, T stage, N stage, EBV-DNA status, and LCR score were independently associated with OS, and a predictive nomogram was developed. The nomogram had a good performance for the prediction of OS [C-index = 0.770 (95% CI: 0.675-0.864)]. and outperformed the traditional staging system [C-index = 0.589 (95% CI: 0.385-0.792)]. The results were internally and additionally validated using independent cohorts.

Conclusion

The pretreatment LCR could independently predict the overall survival in NPC patients. A novel LCR-based prognostic model of an easy-to-use nomogram was established, and it outperformed the conventional staging system in terms of predictive power. Further external verification remains necessary.

Vitamin insufficiency after surgery for oesophagogastric neoplasms: a study protocol for a prospective intervention study

INTRODUCTION

Oesophageal cancer (EC) and gastric cancer (GC) are among the top 10 cancers worldwide. Both diseases impact the nutritional status of patients and their Quality of Life (QoL). Preoperative malnutrition is reported in 42%-80%. However, studies investigating postoperative nutritional status are limited, and postoperative identification and treatment of micronutrient and macronutrient deficiencies are currently lacking in (inter-)national guidelines. The aim of this study is to identify and target micronutrient deficiencies after surgery for oesophagogastric neoplasms.

METHODS

This is a single-centre prospective intervention trial performed in Zuyderland Medical Centre. 248 patients who underwent oesophagectomy (n=124) or (sub)total gastrectomy (n=124) from 2011 until 2022 will be included. Both groups will receive Calcium Soft Chew D3 and a multivitamin supplement (MVS) specifically developed according to the type of operation patients underwent; the oesophagectomy group will receive Multi-E and the gastrectomy group will receive Multi-G. The MVSs will be taken once daily and Calcium Soft Chew D3 two times per day. Supplementation will start after baseline measurements. At baseline (T0), blood withdrawal for micronutrient analysis and faecal elastase-1 analysis for exocrine pancreatic insufficiency (EPI) will be performed. Additionally, patients will receive questionnaires regarding QoL and dietary behaviour. After 180 days of supplementation (T1), baseline measurements will be repeated, and the supplement tolerance questionnaire will be completed. Measurements will also be conducted after 360 days (T2) and after 720 days (T3) of supplementation. The main study parameter is micronutrient deficiency (yes/no) for all measurements. Secondary parameters include occurrence of EPI (n, %), diarrhoea (n, %), steatorrhoea (n, %) or bloating (n, %), time between surgery and start of supplementation (mean in months), and QoL at all time points.

ETHICS AND DISSEMINATION

The study was approved by the Zuyderland Medical Centre Ethics Committee, Heerlen, the Netherlands. The findings will be disseminated through scientific congresses and in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05281380.

The prognostic indicator in breast cancer treated with CDK4/6 inhibitors: the prognostic nutritional index

Aims: The aim of this study was to evaluate the effect of prognostic nutritional index (PNI) on prognosis in patients with hormone receptor-positive, HER2-negative metastatic breast cancer who received CDK4/6 inhibitor + endocrine therapy. Methods: Patients receiving a CDK4/6 inhibitor were evaluated retrospectively. The PNI was calculated as: (10 × serum albumin [g/dl]) + (total lymphocyte count [×10⁹/l] × 5). Results: In a study of 106 patients, a statistically significant survival advantage was observed in the high-PNI group over the low-PNI group (mean overall survival: 28.03 ± 0.487 months vs 22.46 ± 1.14 months; p = 0.013). Conclusion: For the first time in the literature, this study demonstrated the prognostic role of PNI in patients with hormone receptor-positive, HER2-negative metastatic breast cancer treated with CDK4/6 inhibitors.

A Multi-Site, International Audit of Malnutrition Risk and Energy and Protein Intakes in Patients Undergoing Treatment for Head Neck and Esophageal Cancer: Results from INFORM

Patients with foregut tumors are at high risk of malnutrition. Nutrition care focuses on identifying individuals at risk of malnutrition and optimizing nutrient intake to promote the maintenance of body weight and lean body mass. This multi-center prospective, longitudinal study audited nutrition care practices related to screening for risk of malnutrition (Patient-Generated Subjective Global Assessment Short Form; PG-SGA SF), and nutrition interventions prescribed (route; adequacy of energy and protein intakes). Audits occurred at four time periods: baseline (before treatment) and at 2, 4, and 6 months after starting cancer treatment; 170 patients (esophageal (ESO; n = 51); head and neck (HN; n = 119)) were enrolled. Nutrition risk (PG-SGA SF score ≥ 4) was prevalent at every time period: HN (baseline: 60%; 6 months 66%) and ESO (77%; 72%). Both groups had significant (p < 0.001) weight losses over the 6 month audit period (HN = 13.2% ESO = 11.4%). Enteral nutrition (EN) was most likely to be prescribed at 2 months for HN and at 4 and 6 months for ESO. Target prescribed energy and protein intakes were not met with any nutrition intervention; although adequacy was highest for those receiving EN. Nutrition care practices differed for HN and ESO cancers and there may be time points when additional nutrition support is needed.

Nutrition in palliative care: issues, perceptions and opportunities to improve care for patients

Dietary advice, the provision of timely nutritional support and the alleviation of diet-related issues, should be an essential component of a holistic approach to palliative and end-of-life care, adjusted to account for the stage in the patient's journey, including prognosis. With an ageing population and increasing numbers of people living with not just one life-limiting disease but several, the dietary management of these patients is becoming more complex. This article considers the issues patients and families experience, how nurses can play a key role in identifying and alleviating nutrition- and diet-related issues in palliative care, including the use of tools to screen, assess and guide nutrition conversations and interventions. The content of the article is mostly drawn from the literature relating to palliative cancer care, knowledge derived from stakeholder engagement, clinical observations in a dietetic role in a hospice setting and qualitative research on the role of diet in palliative care as perceived by patients, carers, and health professionals.

Model established based on blood markers predicts overall survival in patients after radical resection of types II and III adenocarcinoma of the esophagogastric junction

BACKGROUND

In recent years, the incidence of types II and III adenocarcinoma of the esophagogastric junction (AEG) has shown an obvious upward trend worldwide. The prognostic prediction after radical resection of AEG has not been well established.

AIM

To establish a prognostic model for AEG (types II and III) based on routine markers.

METHODS

A total of 355 patients who underwent curative AEG at The First Affiliated Hospital of Anhui Medical University from January 2014 to June 2015 were retrospectively included in this study. Univariate and multivariate analyses were performed to identify the independent risk factors. A nomogram was constructed based on Cox proportional hazards models. The new score models was analyzed by C index and calibration curves. The receiver operating characteristic (ROC) curve was used to compare the predictive accuracy of the scoring system and tumor-node-metastasis (TNM) stage. Overall survival was calculated using the Kaplan-Meier curve amongst different risk AEG patients.

RESULTS

Multivariate analysis showed that TNM stage (hazard ratio [HR] = 2.286, P = 0.008), neutrophil-to-lymphocyte ratio (HR = 2.979, P = 0.001), and body mass index (HR = 0.626, P = 0.026) were independent prognostic factors. The new scoring system had a higher concordance index (0.697), and the calibration curves of the nomogram were reliable. The area under the ROC curve of the new score model (3-year: 0.725, 95% confidence interval [CI]: 0.676-0.777; 5-year: 0.758, 95%CI: 0.708-0.807) was larger than that of TNM staging (3-year: 0.630, 95%CI: 0.585-0.684; 5-year: 0.665, 95%CI: 0.616-0.715).

CONCLUSION

Based on the serum markers and other clinical indicators, we have developed a precise model to predict the prognosis of patients with AEG (types II and III). The new prognostic nomogram could effectively enhance the predictive value of the TNM staging system. This scoring system can be advantageous and helpful for surgeons and patients.

Nutritional screening in a cancer prehabilitation programme: A cohort study

BACKGROUND

Cancer patients are often malnourished pre-operatively. Study aims were to establish if current screening was appropriate for use in prehabilitation and investigate any association between nutritional risk, functionality and quality of life (QoL).

METHODS

This cohort study used routinely collected data from September 2020 to August 2021 from patients in a Prehab4cancer programme. Included patients were aged >18 years, had colorectal, lung or oesophago-gastric cancer and were scheduled for surgery. Nutritional assessment included patient generated subjective global assessment (PG-SGA) short-form and QoL with a sit-to-stand test. Association between nutritional risk and outcomes were analysed using adjusted logistic regression.

RESULTS

From 928 patients referred to Prehab4Cancer service over 12-months, data on nutritional risk were collected from 526 patients. Pre-operatively, 233 out of 526 (44%) patients were at nutritional risk (score ≥2). During prehabilitation, 31% of patients improved their PG-SGA and 74% of patients maintained or improved their weight. Odds ratios (OR) with confidence intervals (CI) showed that patients with better QoL using EuroQol-5 Dimensions (OR 0.05, 95% CI 0.01, 0.45, P=0.01), EuroQol Visual Analogue Scale (OR 0.96, 95% CI 0.93, 1.00, p=0.04) or sit-to-stand (OR 0.96, 95% 0.93, 1.00, p=0.04) were less likely to be nutritional at risk.

CONCLUSION

Nearly half of patients in Prehab4Cancer programme assessed using PG-SGA were at risk of malnutrition. However, almost half of the sample did not have their risk assessed. Patients at risk of malnutrition were more likely to have a poorer QoL and sit-to-stand test than those who were not at risk. This article is protected by copyright. All rights reserved.

Nutritional Status and Related Factors in Patients with Gastric Cancer after Gastrectomy: A Cross-Sectional Study

Patients after gastrectomy for gastric cancer are at risk of malnutrition, and poor nutritional status negatively affects patients’ clinical outcomes. Knowledge of the factors influencing patients’ nutritional status can inform interventions for improving patients’ nutrition. A cross-sectional study was conducted to describe nutritional status and related factors in gastric cancer patients after gastrectomy. A convenience sample of gastric cancer patients with gastrectomy was recruited from general surgery or oncology clinics of a medical center in northern Taiwan. Data were collected with self-reported questionnaires, including the Functional Assessment Cancer Therapy—Gastric Module version 4, the Concerns in Meal Preparation scale, the Center for Epidemiologic Studies Depression Scale, and the Mini Nutrition Assessment. One hundred and one gastric cancer patients participated in the study. There were 81 cases of subtotal gastrectomy and 20 cases of total gastrectomy. Most patients (52.5%) were malnourished or at risk. Linear regression showed that symptom severity (β = −0.43), employment status (β = 0.19), and difficulty in diet preparation (β = −0.21) were significant predictors of nutritional status. Together, these three variables explained 35.8% of the variance in patient nutritional status (F = 20.3, p < 0.001). More than 50% of our participants were malnourished or at risk for malnutrition, indicating a need for continued monitoring and support after discharge from hospitals. Special attention should be given to patients with severe symptoms, unemployment, and difficulties in diet preparation.

Preoperative Nutritional Status and Risk Factors Associated with Delayed Discharge in Geriatric Patients Undergoing Gastrectomy: A Single-Center Retrospective Study

Objective

Preoperative malnutrition is an independent risk factor for postoperative complications and survival for gastric cancer patients. The study is aimed at investigating the prevalence of malnutrition, perioperative nutritional support, and the risk factors associated with delayed discharge of geriatric patients undergoing gastrectomy.

Methods

A retrospective study of gastric cancer patients (age ≥ 65) who underwent gastrectomy at Zhongshan Hospital from January 2018 to May 2020 was conducted. Clinical data, including demographic information, medical history, surgery-related factors, and perioperative nutritional management, were collected and analyzed. Postoperative complications were assessed according to the Clavien-Dindo grading system, and the prognostic nutritional index (PNI) was calculated. The risk factors affecting the prolongation of postoperative hospital stay were analyzed.

Results

A total of 783 patients were reviewed. The overall frequency of malnutrition was 31.3% (249/783). The albumin, prealbumin, and hemoglobin levels were lower in the malnutrition group than in the well-nourished group. The proportion of patients who received preoperative total parenteral nutritional support in the malnutrition group was significantly higher than in the well-nourished group (12.4% vs. 3.7%, P < 0.001). All patients received postoperative parenteral nutrition (PN); the proportion of patients who received total nutrient admixture (TNA) in the malnutrition group was lower than in the well-nourished group (22.1% vs. 33.5%, P = 0.001). No significant difference was found in the duration of postoperative nutrition between groups (P > 0.05). The malnutrition group was associated with a higher rate of postoperative complications (P < 0.001). Univariate and multivariate regressions revealed that age > 70 years (OR = 1.216, 95% CI 1.048-1.411, P = 0.010), operation time > 180 min (OR = 1.431, 95% CI 1.237-1.656, P < 0.001), PNI < 44.5 (OR = 1.792, 95% CI 1.058-3.032, P = 0.030), and postoperative complications (OR = 2.191, 95% CI 1.604-2.991, P < 0.001) were significant risk factors associated with delayed discharge.

Conclusion

Malnutrition is relatively common in elderly patients undergoing gastrectomy. Advanced age, duration of surgery, lower levels of PNI, and postoperative complications were risk factors associated with delay discharge. Elderly gastric cancer patients with risk factors urgently require specific attention for reducing hospital stay.

Patient perspectives on key symptoms and preferences for follow-up after upper gastro-intestinal cancer surgery

PURPOSE

Long-lasting symptoms and reductions in quality of life are common after oesophago-gastric surgery. Post-operative follow-up has traditionally focussed on tumour recurrence and survival, but there is a growing need to also identify and treat functional sequelae to improve patients' recovery.

METHODS

An electronic survey was circulated via a British national charity for patients undergoing oesophago-gastric surgery and their families. Patients were asked about post-operative symptoms they deemed important to their quality of life, as well as satisfaction and preferences for post-operative follow-up. Differences between satisfied and dissatisfied patients with reference to follow-up were assessed.

RESULTS

Among 362 respondents with a median follow-up of 58 months since surgery (range 3-412), 36 different symptoms were reported as being important to recovery and quality of life after surgery, with a median of 13 symptoms per patient. Most (84%) respondents indicated satisfaction with follow-up. Satisfied patients were more likely to have received longer follow-up (5-year or longer follow-up 60% among satisfied patients vs 27% among unsatisfied, p < 0.001). These were also less likely to have seen a dietitian as part of routine follow-up (37% vs 58%, p = 0.005).

CONCLUSION

This patient survey highlights preferences regarding follow-up after oesophago-gastrectomy. Longer follow-up and dietician involvement improved patient satisfaction. Patients reported being concerned by a large number of gastrointestinal and non-gastrointestinal symptoms, highlighting the need for multidisciplinary input and a consensus on how to manage the poly-symptomatic patient.

Early implementation of a perioperative nutrition support pathway for patients undergoing esophagectomy for esophageal cancer

Background

Unintentional weight loss and malnutrition are associated with poorer prognosis in patients with cancer. Risk of cancer‐associated malnutrition is highest among patients with esophageal cancer (EC) and has been repeatedly shown to be an independent risk factor for worse survival in these patients. Implementation of nutrition protocols may reduce postoperative weight loss and enhance recovery in these patients.

Methods

We retrospectively identified all patients who underwent Ivor Lewis esophagectomy for EC from January 2015 to August 2019 from a prospectively collected institutional database. Patients who underwent surgery after the implementation of this protocol (September 2017–August 2019) were compared with patients who underwent resection before protocol implementation (January 2015–July 2017). Patients undergoing surgery during the month of protocol initiation were excluded.

Results

Of the 404 patients included in our study, 217 were in the preprotocol group, and 187 were in the postprotocol group. Compared with the preprotocol group, there were significant reductions in length of hospital stay (p < 0.001), time to diet initiation (p < 0.001), time to feeding tube removal (p = 0.012), and postoperative weight loss (p = 0.002) in the postprotocol group. There was no significant difference in the incidence of postoperative complications, 30‐day readmission, or mortality rates between groups.

Conclusions

Results of the present study suggest a standardized perioperative nutrition protocol may prevent unintentional weight loss and improve postoperative outcomes in patients with EC undergoing resection.

Assessment of Nutritional Status and Nutrition Impact Symptoms in Patients Undergoing Resection for Upper Gastrointestinal Cancer: Results from the Multi-Centre NOURISH Point Prevalence Study

BACKGROUND

Identification and treatment of malnutrition are essential in upper gastrointestinal (UGI) cancer. However, there is limited understanding of the nutritional status of UGI cancer patients at the time of curative surgery. This prospective point prevalence study involving 27 Australian tertiary hospitals investigated nutritional status at the time of curative UGI cancer resection, as well as presence of preoperative nutrition impact symptoms, and associations with length of stay (LOS) and surgical complications.

METHODS

Subjective global assessment, hand grip strength (HGS) and weight were performed within 7 days of admission. Data on preoperative weight changes, nutrition impact symptoms, and dietary intake were collected using a purpose-built data collection tool. Surgical LOS and complications were also recorded. Multivariate regression models were developed for nutritional status, unintentional weight loss, LOS and complications.

RESULTS

This study included 200 patients undergoing oesophageal, gastric and pancreatic surgery. Malnutrition prevalence was 42% (95% confidence interval (CI) 35%, 49%), 49% lost ≥5% weight in 6 months, and 47% of those who completed HGS assessment had low muscle strength with no differences between surgical procedures (p = 0.864, p = 0.943, p = 0.075, respectively). The overall prevalence of reporting at least one preoperative nutrition impact symptom was 55%, with poor appetite (37%) and early satiety (23%) the most frequently reported. Age (odds ratio (OR) 4.1, 95% CI 1.5, 11.5, p = 0.008), unintentional weight loss of ≥5% in 6 months (OR 28.7, 95% CI 10.5, 78.6, p < 0.001), vomiting (OR 17.1, 95% CI 1.4, 207.8, 0.025), reduced food intake lasting 2-4 weeks (OR 7.4, 95% CI 1.3, 43.5, p = 0.026) and ≥1 month (OR 7.7, 95% CI 2.7, 22.0, p < 0.001) were independently associated with preoperative malnutrition. Factors independently associated with unintentional weight loss were poor appetite (OR 3.7, 95% CI 1.6, 8.4, p = 0.002) and degree of solid food reduction of <75% (OR 3.3, 95% CI 1.2, 9.2, p = 0.02) and <50% (OR 4.9, 95% CI 1.5, 15.6, p = 0.008) of usual intake. Malnutrition (regression coefficient 3.6, 95% CI 0.1, 7.2, p = 0.048) and unintentional weight loss (regression coefficient 4.1, 95% CI 0.5, 7.6, p = 0.026) were independently associated with LOS, but no associations were found for complications.

CONCLUSIONS

Despite increasing recognition of the importance of preoperative nutritional intervention, a high proportion of patients present with malnutrition or clinically significant weight loss, which are associated with increased LOS. Factors associated with malnutrition and weight loss should be incorporated into routine preoperative screening. Further investigation is required of current practice for dietetics interventions received prior to UGI surgery and if this mitigates the impact on clinical outcomes.

Perioperative nutrition management for gastric cancer

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

Preoperative Nutrition Intervention in Patients Undergoing Resection for Upper Gastrointestinal Cancer: Results from the Multi-Centre NOURISH Point Prevalence Study

Background: Preoperative nutrition intervention is recommended prior to upper gastrointestinal (UGI) cancer resection; however, there is limited understanding of interventions received in current clinical practice. This study investigated type and frequency of preoperative dietetics intervention and nutrition support received and clinical and demographic factors associated with receipt of intervention. Associations between intervention and preoperative weight loss, surgical length of stay (LOS), and complications were also investigated. Methods: The NOURISH Point Prevalence Study was conducted between September 2019 and May 2020 across 27 Australian tertiary centres. Subjective global assessment and weight were performed within 7 days of admission. Patients reported on preoperative dietetics and nutrition intervention, and surgical LOS and complications were recorded. Results: Two-hundred patients participated (59% male, mean (standard deviation) age 67 (10)). Sixty percent had seen a dietitian preoperatively, whilst 50% were receiving nutrition support (92% oral nutrition support (ONS)). Patients undergoing pancreatic surgery were less likely to receive dietetics intervention and nutrition support than oesophageal or gastric surgeries (p < 0.001 and p = 0.029, respectively). Neoadjuvant therapy (p = 0.003) and malnutrition (p = 0.046) remained independently associated with receiving dietetics intervention; however, 31.3% of malnourished patients had not seen a dietitian. Patients who received ≥3 dietetics appointments had lower mean (SD) percentage weight loss at the 1-month preoperative timeframe compared with patients who received 0–2 appointments (1.2 (2.0) vs. 3.1 (3.3), p = 0.001). Patients who received ONS for >2 weeks had lower mean (SD) percentage weight loss than those who did not (1.2 (1.8) vs. 2.9 (3.4), p = 0.001). In malnourished patients, total dietetics appointments ≥3 was independently associated with reduced surgical complications (odds ratio 0.2, 95% confidence interval (CI) 0.1, 0.9, p = 0.04), and ONS >2 weeks was associated with reduced LOS (regression coefficient −7.3, 95% CI −14.3, −0.3, p = 0.04). Conclusions: Despite recommendations, there are low rates of preoperative dietetics consultation and nutrition support in this population, which are associated with increased preoperative weight loss and risk of increased LOS and complications in malnourished patients. The results of this study provide insights into evidence–practice gaps for improvement and data to support further research regarding optimal methods of preoperative nutrition support.

The Effectiveness of Nutrition Interventions Combined with Exercise in Upper Gastrointestinal Cancers: A Systematic Review

Malnutrition and muscle wasting are associated with impaired physical functioning and quality of life in oncology patients. Patients diagnosed with upper gastrointestinal (GI) cancers are considered at high risk of malnutrition and impaired function. Due to continuous improvement in upper GI cancer survival rates, there has been an increased focus on multimodal interventions aimed at minimizing the adverse effects of cancer treatments and enhancing survivors’ quality of life. The present study aimed to evaluate the effectiveness of combined nutritional and exercise interventions in improving muscle wasting, physical functioning, and quality of life in patients with upper GI cancer. A comprehensive search was conducted in MEDLINE, EMBASE, Web of Science, Cochrane Library, and CINHAL. Of the 4780 identified articles, 148 were selected for full-text review, of which 5 studies met the inclusion criteria. Whilst reviewed studies showed promising effects of multimodal interventions on physical functioning, no significant differences in postoperative complications and hospital stay were observed. Limited available evidence showed conflicting results regarding the effectiveness of these interventions on preserving muscle mass and improving health-related quality of life. Further studies examining the impact of nutrition and exercise interventions on upper GI patient outcomes are required and would benefit from reporting a core outcome set.

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

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

Comprehensive assessment of nutritional status and nutritional-related complications in newly diagnosed esophageal cancer patients: A cross-sectional study

BACKGROUND & AIMS

Malnutrition is prevalent in upper gastrointestinal cancer patients. The purpose of this study was a comprehensive assessment of nutritional status in newly diagnosed patients with esophageal cancer.

METHODS

Newly diagnosed esophageal cancer patients were referred to a chemo-radiation referral center in Mashhad, Iran, between February 2017 to February 2019. Anthropometric indices, a Patient-Generated Subjective Global Assessment (PG-SGA) tool, body composition, dietary intake, nutritional-related complications, and laboratory tests were assessed.

RESULTS

One hundred and eighty-nine patients with a mean age of 67.1 ± 12 and a male to female ratio of 98 to 91 were included. Ninety-seven (51.3%) of patients had experienced significant weight loss and 56 (29.6%) were underweight at diagnosis. According to PG-SGA, 179 (94.7%) needed nutritional interventions. Reduced muscle mass and low handgrip strength were observed in 70 (39.4%) and 26 (14.4%) of patients, respectively. Inadequate intakes of energy (less than 24 kcal/kg/day) and protein (less than 1.2 g/kg/day) were found in 146 (77.8%) and 171 (91%) patients, respectively. The mean total daily energy and protein intakes of subjects were 943.8 ± 540 kcal/day, and 30.6 ± 21 g/day, respectively. The most common nutritional-related complications were as follows: dysphagia (84.8%), anorexia (31.6%), constipation (62.1%), esophageal pain (48.4%), and dyspepsia (41.1%).

CONCLUSION

Our study demonstrated a high prevalence of malnutrition in newly diagnosed esophageal cancer patients. This fact demonstrates the importance of early screening of nutritional status via PG-SGA tool, clinical evaluation, dietary intake evaluations, and laboratory tests, based on which effective nutritional interventions and Symptoms management may be introduced in these patients.

Oral nutrition interventions in patients undergoing gastrointestinal surgery for cancer: A systematic literature review

PURPOSE

Weight loss and poor food intake have been shown to affect several outcomes in patients undergoing surgery for gastrointestinal cancer. This review aims to examine the effect of pre-, post- or perioperative nutrition interventions focused on increasing oral energy or protein intake in patients undergoing surgery for gastrointestinal cancer. Interventions using standard oral nutrition supplements and/or dietary counselling were included. The primary outcome was weight change, and secondary outcomes were energy and protein intake. A secondary aim was to examine this effect in malnourished patients.

METHODS

Embase, Medline, CINAHL and CENTRAL were searched from inception to September 2019 for relevant randomised controlled trials. Study quality was assessed using the revised Cochrane Collaboration risk of bias tool for randomised trials. The quality of evidence for each outcome was assessed using GRADE.

RESULTS

Fourteen articles met the inclusion criteria. Studies assessed patients undergoing surgery for gastric, colorectal, oesophageal and pancreatic cancers. The interventions studied included oral nutrition supplements and/or dietary counselling. Five studies reported preoperative interventions; five studies reported post-operative interventions; six studies reported post-discharge interventions; and two studies reported perioperative interventions. Overall, low or very low quality evidence was found to support the use of oral nutrition supplements to positively influence weight and increase energy and protein intake in the preoperative period and immediate post-operative period. Very low quality evidence was found to support the use of oral nutrition interventions to influence weight, energy or protein intake in the post-discharge period. Very limited evidence with high risk of bias was found to support positive effects of nutrition intervention in malnourished patients.

CONCLUSIONS

This review demonstrates limited evidence for the use of oral nutrition supplements to increase intake and positively influence weight in patients undergoing surgery for gastrointestinal cancer. Overall, results were heterogeneous leading to inconsistent results. Further research into optimal nutrition support interventions and timing of interventions is required.

Nutritional and Clinical Factors Affecting Weight and Fat-Free Mass Loss after Gastrectomy in Patients with Gastric Cancer

After a gastrectomy, the nutritional status of patients with gastric cancer has great effect on the treatment outcome and patients' quality of life. We investigated the changes in body composition and nutrient intake after gastrectomy in 288 gastric cancer patients. A multiple linear regression analysis was used for each time period to verify the effects of nutritional and clinical factors on weight and fat-free mass loss rates. Gastric cancer patients who underwent a gastrectomy continued to experience weight and fat-free mass loss until three months after surgery and became stagnant at six months. The marginal mean of calorie intake per weight was 24.5, 26.8, and 29.4 kcal at one, three, and six months. The protein intake per kg lean mass was 1.14, 1.14, and 1.16 g at one, three, and six months, respectively. One month after surgery, the rate of weight loss increased significantly in females who received chemotherapy (p < 0.001). At one to three months postoperative, females who had undergone chemotherapy tended to significantly lose weight (p = 0.016). Females with a history of chemotherapy also showed a reduction in fat-free mass for one to three months (p = 0.036). Calorie intake was a significant factor in preventing fat-free mass weight loss at one month after surgery. Chemotherapy was an independent factor affecting the weight and fat-free mass loss rate up to six months after gastrectomy. Careful monitoring of weight and muscle mass changes following active nutritional intervention for sufficient nutrition support could be helpful for patients after gastrectomy.

utritional Outcomes of patients Undergoing Resection for upper gastroIntestinal cancer in AuStralian Hospitals (NOURISH): protocol for a multicentre point prevalence study

INTRODUCTION

Nutritional intervention and prevention of malnutrition is significantly important for patients with upper gastrointestinal oesophageal, pancreatic and gastric cancer. However, there is limited information regarding nutritional status, and perioperative nutritional interventions that patients receive when undergoing curative surgery.

METHODS AND ANALYSIS

Patients diagnosed with upper gastrointestinal cancer, planned for curative intent resection across 27 Australian hospitals will be eligible to participate in this point prevalence study. The primary aim is to determine the prevalence of malnutrition in patients with upper gastrointestinal cancer at the time of surgery using subjective global assessment. Secondary aims are to determine the type and frequency of perioperative nutritional intervention received, the prevalence of clinically important weight loss and low muscle strength, and to investigate associations between the use of an evidence-based nutrition care pathway or protocol for the nutritional management of upper gastrointestinal surgical oncology patients and malnutrition prevalence. Data collection will be completed using a purpose-built data collection tool.

ETHICS AND DISSEMINATION

Ethical approval was granted in May 2019 (LNR/51107/PMCC-2019). The design and reporting of this study comply with the Strengthening the Reporting of Observational Studies in Epidemiology checklist for reporting of observational cohort studies. Findings will be published in peer-reviewed scholarly journals and presented at relevant conferences. Results will assist in defining priority areas for research to improve patient outcomes.

The Value of Prognostic Nutritional Index (PNI) in Predicting Survival and Guiding Radiotherapy of Patients With T1-2N1 Breast Cancer

Background: To investigate the significance of the prognostic nutrition index (PNI) as a predictor of survival and guide for treating T1-2N1 breast cancer.

Methods: Patients with T1-2N1 breast cancer (N = 380) who underwent a mastectomy at our center were studied. PNI was calculated as 10 × serum albumin (g/dl) + 0.005 × total lymphocyte count (per mm³). The cutoff for the PNI was calculated using the time-dependent receiver operating characteristic (ROC) curve analysis by overall survival (OS) prediction. The associations between the PNI and the clinicopathologic characteristics were analyzed using Pearson's χ² test. Survival curves were calculated using the Kaplan–Meier method. Univariate and multivariate analyses were performed using the Cox proportional hazards model.

Results: Subgroup analyses of patients with low PNI value (≤52.0) and high PNI value (>52.0) showed that a high PNI was significantly associated with HER2 status, the neutrophil–lymphocyte ratio (NLR), the monocyte–lymphocyte ratio (MLR), and KI 67 status. The OS of patients with a high PNI was significantly better than that of patients with a low PNI. We then conducted subgroup analyses based on PNI and radiotherapy. Among patients who received radiotherapy, the OS of those with a high PNI was significantly better than that of patients with a low PNI. Among patients with a high PNI, the OS of those who received radiotherapy was better than that of the patients who did not receive radiotherapy. However, among the patients with a low PNI, the OS of those who received radiation was worse than that of patients who did not receive radiotherapy. The Kaplan–Meier survival analysis and the multivariate analysis of patients with T1-2N1 breast cancer who received radiotherapy showed PNI independently predicted OS.

Conclusions: The preoperative PNI may be a reliable predictor of OS of patients with operable T1-2N1 breast cancer, with the capacity to provide a personalized prognosis and facilitate the development of clinical treatment strategies. However, radiotherapy did not achieve satisfactory outcomes in patients with PNI ≤52.0; thus, further studies on treatment optimization are needed.

The Impact of the Disease Trend on the Macro and Micro-Nutrients Intake in Patients with Gastric Cancer

Background: Disease-related malnutrition, as a major cause of morbidity and mortality in cancer patients, is very common in patients with gastric cancer (GC). Malnutrition in cancer patients was reported to have important adverse effects, including a decreased response and tolerance to treatment, a decrease of performance, shorter survival, and lower quality of life. The treatment approaches involving chemotherapy is known to develop various acute and chronic symptoms that restrict eating and, thereby, exert a profound impact on nutritional status.Method: In this study, 82 patients with GC with an average age of 48.33 ± 10.74 were enrolled. Patients were followed up for 6 months without any nutritional intervention and/or education. A 168 item semi-quantities food frequency questioner was completed by a trained nutritionist at the beginning of the study and six months after the start of chemotherapy.Results: Intake of vitamin A (T₀:585.52 ± 203.34 vs. T₆:529.48 ± 138.91, t = 2.96), Thiamin (T₀:2.09 ± 0.76 vs. T₆:1.80 ± 0.72, t = 2.81), vitamin B6 (T₀:2.03 ± 0.53 vs. T₆:2.29 ± 0.73, t = 2.56), and vitamin B12 (T₀:5.79 ± 3.96 vs. T₆:4.48 ± 2.20, t = 2.43) significantly decreased after 6 months of receiving chemotherapy. On the other intake of beef (T0:17.79 ± 25.48 vs. T6:12.58 ± 16.66, t = 2.06), low-fat milk (T0:52.57 ± 69.80 vs. T6:29.18 ± 45.89, t = 2.95), cream (T0:2.42 ± 4.16 vs. T6:1.06 ± 1.68, t = 2.88), and raw vegetable (T0:6.54 ± 9.55 vs. T6:3.85 ± 5.23, t = 2.54) significantly decreased.Conclusion: Nutritional deterioration is an important part of the pathogenesis of cancer and its treatment that can occur at any point in the timeline of cancer diagnosis, treatment or support. Therefore nutritional counseling and supportive services are needed for cancer patients, especially when their disease is diagnosed.