Malnutrition in Patients With Cancer: Comparison of Perceptions by Patients, Relatives, and Physicians-Results of the NutriCancer2012 Study

Prevalence and survival implications of malnutrition and sarcopenia in metastatic breast cancer: A longitudinal analysis

BACKGROUND

Malnutrition and sarcopenia are challenges for patients with metastatic breast cancer and have been proposed as independent prognostic factors. Very few studies have addressed the temporal evolution of these parameters and, notably, the separate and combined analysis of sarcopenia and malnutrition. This study aimed to i) determine the prevalence of malnutrition and sarcopenia, individually and combined, and their evolution over time, ii) identify risk factors for each condition, and iii) explore their impact on overall survival (OS).

METHODS

This retrospective study was conducted on 111 patients treated for at least a third-line metastatic breast cancer at the Institut Curie between January 1st and March 31st, 2018. Solitary malnutrition was defined from weight loss and body mass index values while solitary sarcopenia was defined solely based on low muscle mass. We analyzed solitary malnutrition, solitary sarcopenia, and then malnutrition with or without sarcopenia, at three key stages (T1: diagnosis of metastasis, T2: initiation of third-line treatment, and T3: 3-month re-evaluation). Univariate and multivariate logistic regression analyses were conducted to investigate the risk factors. We performed Cox proportional hazards analyses for each variable.

RESULTS

At T1, the prevalence of solitary malnutrition, solitary sarcopenia and malnutrition with or without sarcopenia was 18.6%, 36.1% and 48.9% respectively, increasing to 27.7%, 45.5% and 56.6% at T2. At T2, in multivariate logistic regression analyses, patients aged over 60 years were at an elevated risk of experiencing solitary malnutrition as well as malnutrition with or without sarcopenia, but not solitary sarcopenia. In multivariate analyses, solitary malnutrition was significantly associated with poorer OS (HR 2.2 [95% CI 1.1-4.1], p = 0.02), while solitary sarcopenia and malnutrition with or without sarcopenia showed no association.

CONCLUSION

Solitary malnutrition and sarcopenia were highly prevalent in patients with metastatic breast cancer, affecting around a quarter and half of patients respectively at third-line treatment initiation. Notably, solitary malnutrition emerged as a prognostic factor for overall survival, whereas no significant association was observed for solitary sarcopenia or malnutrition with or without sarcopenia. This highlights the critical need for early identification of patients at risk of malnutrition and the importance of timely intervention.

Correlation between changes in nutritional status and tumor response in patients receiving immunotherapy for lung cancer (NUTIMMUNO study)

Malnutrition is a common condition in lung cancer, and it is an independent prognostic factor. The main objective of this study was to determine whether an early improvement at 3 months in the nutritional status (NS) of patients undergoing immune checkpoint inhibitor (ICI) is associated with a tumor response to treatment at 6-month follow-up. The clinical data of 106 patients initiating ICI for bronchopulmonary non-small cell lung cancer (NCSLC) were retrospectively reviewed. NS was defined according to the HAS 2019 recommendation, depending on BMI, percentage of weight loss, and albuminemia. NS was assessed at baseline (M0) and 3 months (M3) after ICI treatment initiation according to 3 categories: well-nourished, malnourished, and very malnourished. The NS evolution of the 92 patients who were still alive at 3 months was determined. The proportion of patients with malnutrition at M0 and M3 was 39.6% and 43.3%. Median follow-up was 18.7 months. OS and PFS were longer for patients in the M0 well-nourished group than in the malnourished and very malnourished groups. Patients who remained well-nourished had a significantly better ICI success rate at 6 months than patients who remained malnourished or improved or deteriorated their NS. OS was significantly longer for remaining well-nourished patients compared to the amelioration group and the degradation group. PFS was not significantly modified between the 4 evolution groups. Maintaining good NS during the first months of ICI treatment leads to better OS and objective response rate than remaining malnourished or early deteriorating NS. However, an early improvement in NS does not seem to predict a good tumor response to treatment and not a better OS either.

[Nutritional management of patients during surgical prehabilitation and rehabilitation programs]

Undernutrition (UD) increases perioperative morbidity and mortality. Its prevention and treatment are therefore essential in surgical prehabilitation and rehabilitation programs. Nutritional treatment is individualized according to the patient's nutritional status, ingesta and protein-energy requirements. Oral nutrition is optimized to increase intakes through personalized dietary advice and oral nutritional supplements. Artificial nutrition support is indicated in cases of UD or high risk of UD before major surgery. Enteral nutrition is preferred to parenteral nutrition when the digestive tract is functional.

Nutritional Assessment Tools for Patients with Cancer: A Narrative Review

Cancer patients are at high risk of malnutrition, which can lead to adverse health outcomes such as prolonged hospitalization, increased complications, and increased mortality. Accurate and timely nutritional assessment plays a critical role in effectively managing malnutrition in these patients. However, while many tools exist to assess malnutrition, there is no universally accepted standard. Although different tools have their own strengths and limitations, there is a lack of narrative reviews on nutritional assessment tools for cancer patients. To address this knowledge gap, we conducted a non-systematic literature search using PubMed, Embase, Web of Science, and the Cochrane Library from their inception until May 2023. A total of 90 studies met our selection criteria and were included in our narrative review. We evaluated the applications, strengths, and limitations of 4 commonly used nutritional assessment tools for cancer patients: the Subjective Global Assessment (SGA), Patient-Generated Subjective Global Assessment (PG-SGA), Mini Nutritional Assessment (MNA), and Global Leadership Initiative on Malnutrition (GLIM). Our findings revealed that malnutrition was associated with adverse health outcomes. Each of these 4 tools has its applications, strengths, and limitations. Our findings provide medical staff with a foundation for choosing the optimal tool to rapidly and accurately assess malnutrition in cancer patients. It is essential for medical staff to be familiar with these common tools to ensure effective nutritional management of cancer patients.

Malnutrition prevalence in cancer patients in Belgium: The ONCOCARE study

RATIONALE

Unintentional weight loss and malnutrition are common among cancer patients. Malnutrition has been associated with impaired health-related quality of life, less well-tolerated chemotherapy regimens and shorter life duration. In Belgium there is a lack of epidemiological data on malnutrition in oncology patients at advanced stages of the disease.

METHODS

Malnutrition assessment data was collected through a prospective, observational study in 328 patients who started a neoadjuvant anticancer therapy regimen or who started 1st, 2nd or 3rd line anticancer therapy for a metastatic cancer via 3 visits according to regular clinical practice (baseline visit (BV) maximum 4 weeks before start therapy, 1st Follow up visit (FUV1) ± 6 weeks after start therapy, FUV2 ± 4 months after start therapy). Malnutrition screening was evaluated using the Nutritional Risk Screening score 2002 (NRS-2002)and the diagnosis of malnutrition by the GLIM criteria. In addition, SARC-F questionnaire and Fearon criteria were used respectively to screen for sarcopenia and cachexia.

RESULTS

Prevalence of malnutrition risk at BV was high: 54.5% of the patients had a NRS ≥ 3 (NRS 2002) and increased during the study period (FUV1: 73.2%, FUV2: 70.1%). Prevalence of malnutrition based on physician subjective assessment (PSA) remained stable over the study period but was much lower compared to NRS results (14.0%-16.5%). At BV, only 10% of the patients got a nutrition plan and 43.9% received ≤ 70% of nutritional needs, percentage increased during FU period (FUV1: 68.4%, FUV2: 67.6%). Prevalence of sarcopenia and cachexia were respectively 12.4% and 38.1% at BV and without significant variation during the study period, but higher than assessed by PSA (11.6% and 6.7% respectively). Figures were also higher compared to PSA. There were modifications in cancer treatment at FUV1 (25.2%) and at FUV2 (50.8%). The main reasons for these modifications at FUV1 were adverse events and tolerability. Patient reported daily questionnaires of food intake showed early nutritional deficits, preceding clinical signs of malnutrition, and therefore can be very useful in the ambulatory setting.

CONCLUSIONS

Prevalence of malnutrition and cachexia was high in advanced cancer patients and underestimated by physician assessment. Earlier and rigorous detection of nutritional deficit and adjusted nutritional intake could lead to improved clinical outcomes in cancer patients. Reporting of daily caloric intake by patients was also very helpful with regards to nutritional assessment.

Long-term survival in a patient with multiple metastatic gastric cancer treated with PTX plus emvolimab and disitamab vedotin: case report and treatment experience: A case report

RATIONALE

Most Chinese patients with locally advanced gastric cancer at diagnosis have an overall 5-year survival rate of <50%. Surgical resection alone is not suitable for patients with locally advanced gastric cancer. Currently, comprehensive treatment is the focus of locally advanced gastric cancer.

PATIENTS CONCERNS

The patient, a 56-year-old female, was admitted to the hospital because of "4 + months of double hydronephrosis found during a physical examination." Who was admitted for computer tomography and gastroscopy examinations, and take pathological tissue specimens during endoscopic examination.

DIAGNOSES

Computed tomography assessment indicated ulcerative gastric cancer with an abdominal implant, bladder, and bone metastases. An endoscopic examination revealed that the ulcer of the gastric angle was huge, and through relevant auxiliary examinations, the diagnosis of this disease is gastric cancer complicated with multiple metastases to bladder, rectum, lumbar spine, and peritoneum. Clinically diagnosed as cT4bN3M1.

INTERVENTIONS

The patient is currently undergoing first, second, and third line neoadjuvant therapy, combined with immunotherapy, targeted therapy, neoadjuvant intraperitoneal systemic chemotherapy, nutritional support, and other treatment plans.

OUTCOMES

After 15 cycles of treatment, the progression-free survival had reached 15 months. The patient had an NRS2002 score of 1, an ECOG score of I, a quality of life score of 55, albumin of 35.27 g/L, and a decrease in abdominal and pelvic fluid accumulation and exudation compared to before.

LESSONS

We demonstrated high survival of almost 3 years in a patient with gastric cancer that was complicated by bone, peritoneal, rectal, and bladder metastases. The combination of immunotherapy, targeted therapy, and neoadjuvant intraperitoneal systemic chemotherapy, along with the maintenance of nutritional status and CTCs could be a valuable modality for the subsequent treatment and observation of similar patients.

Association of Malnutrition Diagnosed Using Global Leadership Initiative on Malnutrition Criteria with Severe Postoperative Complications After Gastrectomy in Patients with Gastric Cancer

Background: The purpose of this study was to investigate the relationship between malnutrition assessed by the Global Leadership Initiative on Malnutrition (GLIM) criteria and the occurrence of severe postoperative complications (SPCs) after gastrectomy in patients with gastric cancer. Methods: A total of 220 patients with gastric cancer were included in this retrospective study. According to the GLIM criteria, the first step was to use the Nutrition Risk Screening Score 2002 to conduct nutritional risk screening for patients and the second step was to diagnose and grade the severity of malnutrition in patients at risk of malnutrition. According to the Clavien-Dindo classification system, SPCs were defined as C-D Grade IIIa or higher. Results: Overall, 66 (30.0%) patients were diagnosed with malnutrition, including 32 (14.5%) with moderate malnutrition and 34 (15.5%) with severe malnutrition. The incidence of SPCs was 14.5%, and the most frequent postoperative event was anastomotic leakage. In the multivariate regression analysis, malnutrition was considered an independent risk factor for SPCs (P < .001). After adjusting for various factors, the grading association remained statistically significant. Compared with patients with normal nutrition, patients with moderate and severe malnutrition have a nearly 15-fold (OR = 15.682, 95% CI: 4.481-54.877, P < .001) and 20-fold (OR = 20.554, 95% CI: 5.771-73.202, P < .001) increased risk of developing SPCs, respectively. Conclusions: Malnutrition assessed by GLIM was an independent risk factor for SPCs in gastric cancer patients. Therefore, early identification of malnourished patients is crucial for timely implementation of nutritional treatment and reducing the occurrence of postoperative complications.

Nutrition Care after Hospital Discharge in Singapore: Evidence-Based Best-Practice Recommendations

The nutritional status of hospitalised patients is often at risk or compromised and predisposed to further deterioration after discharge, leading to poor clinical outcomes, high healthcare costs, and poor quality of life. This paper aims to provide evidence-based best-practice recommendations to address this, supported by a national survey of healthcare professionals in Singapore and reviewed by a multidisciplinary expert panel under the Sarcopenia Interest Group of Society of Parenteral and Enteral Nutrition Singapore (SingSPEN). We advocate screening all patients with a validated tool which includes a disease activity/burden component, an easily accessible dietitian referral pathway for patients at risk of malnutrition, and an individualised nutrition care plan formulated and delivered using a multidisciplinary team approach for patients at risk or with malnutrition. A comprehensive team would include not only dietitians but also physicians, nurses, physiotherapists, speech therapists, and medical social workers working together towards a common goal. Information on why nutrition is important for good health and how it can be achieved should also be provided to all patients and their caregivers before and after hospital discharge. With the above recommendations, we seek to improve upon the current nutrition care processes at discharge for healthcare institutions in Singapore.

Nutrition as prevention for improved cancer health outcomes: a systematic literature review

BACKGROUND

Among adults with cancer, malnutrition is associated with decreased treatment completion, more treatment harms and use of health care, and worse short-term survival. To inform the National Institutes of Health Pathways to Prevention workshop, "Nutrition as Prevention for Improved Cancer Health Outcomes," this systematic review examined the evidence for the effectiveness of providing nutrition interventions before or during cancer therapy to improve outcomes of cancer treatment.

METHODS

We identified randomized controlled trials enrolling at least 50 participants published from 2000 through July 2022. We provide a detailed evidence map for included studies and grouped studies by broad intervention and cancer types. We conducted risk of bias (RoB) and qualitative descriptions of outcomes for intervention and cancer types with a larger volume of literature.

RESULTS

From 9798 unique references, 206 randomized controlled trials from 219 publications met the inclusion criteria. Studies primarily focused on nonvitamin or mineral dietary supplements, nutrition support, and route or timing of inpatient nutrition interventions for gastrointestinal or head and neck cancers. Most studies evaluated changes in body weight or composition, adverse events from cancer treatment, length of hospital stay, or quality of life. Few studies were conducted within the United States. Among intervention and cancer types with a high volume of literature (n = 114), 49% (n = 56) were assessed as high RoB. Higher-quality studies (low or medium RoB) reported mixed results on the effect of nutrition interventions across cancer and treatment-related outcomes.

CONCLUSIONS

Methodological limitations of nutrition intervention studies surrounding cancer treatment impair translation of findings into clinical practice or guidelines.

Prognostic impact of geriatric nutritional risk index on patients with urological cancers: A meta-analysis

Background

Despite previous research examining the predictive value of the geriatric nutritional risk index (GNRI) in individuals with urological cancers (UCs), results have been conflicting. This study aimed to comprehensively explore the potential link between GNRI and the prognosis of UCs using a meta-analysis.

Methods

The Cochrane Library, PubMed, Embase, and Web of Science databases were systematically and exhaustively searched. We estimated the prognostic importance of the GNRI in patients with UCs by calculating the pooled hazard ratios (HRs) and 95% confidence intervals (CIs) on survival outcomes. Publication bias was identified using Egger's test and Begg's funnel plot.

Results

Eight trials with 6,792 patients were included in our meta-analysis. Patients with UCs who had a lower GNRI before treatment had a higher risk of experiencing worse overall survival (HR = 2.62, 95% CI = 1.69-4.09, p < 0.001), recurrence-free survival/progression-free survival (HR = 1.77, 95% CI = 1.51-2.08, p < 0.001), and cancer-specific survival (HR = 2.32, 95% CI = 1.28-4.20, p = 0.006). Moreover, the subgroup analysis did not change the predictive significance of the GNRI in individuals with UCs. Neither Egger's nor Begg's test indicated substantial bias in this analysis.

Conclusion

As a result of our meta-analysis, we found that a low GNRI strongly predicts poor prognosis for patients with UCs. A lower pretreatment GNRI indicates poor survival outcomes in UCs.

Nutritional management of cancer patients in clinical practice in Spain: patients' and multidisciplinary health care professionals' perceptions

BACKGROUND/OBJECTIVES

Malnutrition is a prevalent problem in patients with cancer and is associated with poor prognosis. The European Society for Clinical Nutrition and Metabolism (ESPEN) recommends the provision of nutritional support and evaluation. This study aims to describe the nutritional management of patients with cancer, including assessment of adherence, from the perspective of both patients and healthcare professionals (HCPs).

SUBJECTS/METHODS

A cross-sectional descriptive observational study was carried out through two surveys addressed to patients and HCPs.

RESULTS

A total of 230 cancer patients and 461 HCPs completed the questionnaire. The survey found 55.0% of patients experienced eating problems during treatment and 64.0% reported sequelae affecting nourishment. However, 60.1% of patients and 42.6% of HCPs indicated that nutritional status is not generally assessed. While 86.6% of HCPs stated that nutritional information is provided to patients, only 33.5% of patients reported having received it. Regarding nutritional adherence, 87.4% of HCPs stated that it is assessed whereas only 49.2% of patients receiving nutritional supplements confirmed this. General discomfort or gastrointestinal problems were the main issues hampering correct adherence perceived by both patients (41.8%) and HCPs (95.4%).

CONCLUSIONS

Our study demonstrate that different perceptions exist between patients and HCPs about nutritional management in cancer and suggests that in Spain nutritional approach is suboptimal in terms of screening/assessment of malnutrition, nutritional information provided to the patient, nutritional intervention and assessment of adherence to nutritional support. Therefore, measure should be taken to foster the adoption of ESPEN recommendations in clinical practice and to promote nutritional education of HCPs.

Home Artificial Nutrition and Energy Balance in Cancer Patients: Nutritional and Clinical Outcomes

Malnutrition is one of the main factors determining cachexia syndrome, which negatively impacts the quality of life and survival. In cancer patients, artificial nutrition is considered as an appropriate therapy when the impossibility of an adequate oral intake worsened nutritional and clinical conditions. This study aims to verify, in a home palliative care setting for cancer patients, if home artificial nutrition (HAN) supplies a patient’s energy requirement, improving nutritional and performance status. A nutritional service team performed counseling at a patient’s home and assessed nutritional status (body mass index, weight loss in the past 6 months), resting energy expenditure (REE), and oral food intake; Karnofsky Performance Status (KPS); cachexia degree; and survival. From 1990 to 2021, 1063 patients started HAN. Among these patients, 101 suspended artificial nutrition for oral refeeding. Among the 962 patients continuing HAN until death, 226 patients (23.5%) survived 6 weeks or less. HAN allowed to achieve a positive energy balance in 736 patients who survived more than 6 weeks, improving body weight and KPS when evaluated after 1 month of HAN. Advanced cancer and cachexia degree at the entry of the study negatively affected the positive impact of HAN.

Malnutrition management in oncology: An expert view on controversial issues and future perspectives

Cancer and anticancer treatments can lead to several negative side effects, including malnutrition. Despite the recognized need for adequate nutritional support in cancer patients, in daily clinical practice, nutrition is still not considered one of the first aspects to be considered. Malnutrition negatively affects the clinical outcomes, treatment response, and overall survival of cancer patients. In this study, three of the most controversial issues related to malnutrition, which emerged during an Italian Consensus Conference, were addressed specifically for patients with head and neck as well as gastrointestinal cancer. The timing of nutritional evaluation and intervention, extension of the Enhanced Recovery after Surgery (ERAS^®) protocols, and cost-effectiveness of nutritional interventions have been considered. This study aimed to illustrate the state-of-the art of each issue and hypothesize future perspectives and actions to be taken, trying to suggest a new nutritional management model for cancer patients in Italy that overcomes the critical issues encountered. Of note, the timely diagnosis of nutritional issue appears to be essential to ensure the correct management of malnourished cancer patients as well as those who are at high risk of malnutrition. Standardized protocols, screening tests, and the inclusion of nutritional parameters in patient medical records would help to achieve good clinical outcomes. Finally, appropriate nutritional support is also associated with cost savings, and it seems necessary to promote its clinical and economic value to obtain improvements in both outcomes and management costs.

Nutrition Risk Screening and Related Factors Analysis of Non-hospitalized Cancer Survivors: A Nationwide Online Survey in China

Purposes

This study investigated the nutritional problems and risks of Chinese non-hospitalized cancer survivors through an online survey.

Methods

The survey included nutritional and clinical questions distributed to non-hospitalized cancer survivors. All data were screened and analyzed with strict quality control. Nutrition Risk Screening-2002 (NRS-2002) was adopted and the related factors were analyzed.

Results

Six thousand six hundred eighty-five questionnaires were included. The prevalence of nutritional risk was 33.9%, which varied according to age, sex, cancer type, TNM staging, oncologic treatment, time interval since last treatment, etc. In the regression analysis, nutritional risk was associated with age, TNM staging, and nutrition support. Patients with leukemia and digestive cancer had the highest NRS-2002 score (3.33 ± 1.45 and 3.25 ± 1.61); the prevalence of nutritional risk (NRS-2002 ≥ 3) was 66.7 and 55.1%, respectively. Patients with a higher TNM stage had higher NRS-2002 scores in non-digestive cancer, which was not seen in digestive cancer. Among digestive, bone, nervous, and respiratory cancer patients, the NRS-2002 score mainly consisted of “impaired nutritional status,” which coincided with the “disease severity score” in leukemia patients. Nutrition intervention was achieved in 79.7 and 15.2% of patients with nutritional risk and no risk. Of the patients, 60.3% exhibited confusion about nutritional problems, but only 25.1% had professional counseling.

Conclusions

Regular nutritional risk screening, assessment, and monitoring are needed to cover non-hospitalized cancer survivors to provide nutrition intervention for better clinical outcome and quality of life. By online survey, the nutritional risk of non-hospitalized cancer survivors was found high in China, but the nutrition support or professional consultation were not desirable. The composition of nutritional risk should also be aware of.

De novo Creation and Assessment of a Prognostic Fat-Age-Inflammation Index “FAIN” in Patients With Cancer: A Multicenter Cohort Study

Background and Aims

Malnutrition is highly prevalent and is related to multiple impaired clinical outcomes in cancer patients. This study aimed to de novo create an objective, nutrition-related index specially for prognostic purposes in oncology populations.

Methods

We performed a multicenter cohort study including 14,134 cancer patients. The prognostic impact for each baseline characteristic was estimated by calculating Harrell's C-index. The optimal parameters reflecting the nutritional and inflammatory impact on patients' overall survival were selected to develop the fat-age-inflammation (FAIN) index. The associations of the FAIN with the nutritional status, physical performance, quality of life, short-term outcomes and mortality of patients were comprehensively evaluated. Independent external validation was performed to further assess the prognostic value of the FAIN.

Results

The study enrolled 7,468 men and 6,666 women with a median age of 57 years and a median follow-up of 42 months. The FAIN index was defined as: (triceps skinfold thickness + albumin) / [age + 5 × (neutrophil count/lymphocyte count)]. There were significant associations of the FAIN with the nutritional status, physical performance, quality of life and short-term outcomes. The FAIN also showed better discrimination performance than the Nutritional Risk Index, the Prognostic Nutritional Index and the Controlling Nutritional Status index (all P < 0.05). In multivariable-adjusted models, the FAIN was independently associated with a reduced death hazard both as a continuous variable (HR = 0.57, 95%CI = 0.47–0.68) and per one standard deviation (HR = 0.83, 95%CI = 0.78–0.88). External validation in a multicenter lung cancer cohort (n = 227) further confirmed the prognostic value of the FAIN.

Conclusions

This study created and assessed the prognostic FAIN index, which might act as a feasible option to monitor the nutritional status and help develop intervention strategies to optimize the survival outcomes of cancer patients.

Preoperative nutritional evaluation of prostate cancer patients undergoing laparoscopic radical prostatectomy

Background and objective

Prostate cancer (PCa) is one of the most common malignant tumors in men. Geriatric Nutritional Risk Index (GNRI) is an objective index for evaluating nutritional status of elderly people over 65 years old. The aim of the current study was to explore the correlation and predictive value between GNRI and postoperative recovery and complications in PCa patients undergoing laparoscopic radical prostatectomy (LRP).

Methods

Taking 98 as the GNRI boundary value, 96 PCa patients (aged≥65 y) undergoing LRP in the Department of Urology, Affiliated Hospital of North Sichuan Medical College from January 2018 to December 2020 were grouped into malnutrition group (MNg, 34 patients, 35.4%) and normal nutrition group (NNg, 62 patients, 64.6%). Basic information, laboratory examination indexes, operation conditions, postoperative complications and postoperative recovery indexes of patients were recorded and retrospectively analyzed. Clavien-Dindo Classification System (CDCS) was used to assess postoperative complications. T-test was used to analyze differences between the two groups. ROC curve was generated to determine the predictive value of GNRI for postoperative complications.

Results

Percentage of complications was significantly higher in MNg group compared with that in NNg group (P < 0.01). The average grade based on CDCS was significantly lower in NNg group compared with that in MNg group (P < 0.01). Body weight, Body Mass Index (BMI), preoperative hemoglobin value (HGB), serum albumin (ALB) values of MNg and NNg were significantly positively correlated with GNRI (P<0.01). Incidence and severity of postoperative complications of MNg patients were significantly higher compared with those of NNg patients (P<0.05). Average hospitalization cost of MNg patients was higher in MNg patients compared with that of NNg patients (P<0.05). Duration of post-anesthesia care unit (PACU), duration of antibiotic use and duration of indwelling drainage tube were longer in MNg patients compared with those in NNg patients (P<0.05). Furthermore, volume of indwelling drainage tube was higher in MNg patients compared with that in NNg patients (P<0.05).

Conclusion

GNRI is an effective and reliable tool for evaluation of preoperative nutritional status of prostate cancer patients. The findings showed that GNRI is correlated with postoperative recovery and complications, and is an effective predictive marker.

Nutritional status disorders and methods of their correction in patients with advanced pancreatic cancer

Despite of achieved progress in advanced pancreatic cancer treatment, the disease outcomes remain far from satisfying. The peculiarity of malnutrition treatment in these patients is the result of its causes complexity and progressively growing manifestations extent. The review represents mechanisms of malnutrition and approaches to their treatment.

Increased Emergency Department Utilization and Costs for Medicare Cancer Patients with Malnutrition Diagnoses

BACKGROUND

Malnutrition or its risk affects up to 70% of cancer patients. Compared to adequately nourished oncology patients, those with malnutrition experience more complications and have poorer prognoses, thus higher needs for healthcare. We compared utilization of emergency department (ED) services and costs for Medicare-covered cancer patients with or without a malnutrition diagnosis.

METHODS

We used the Centers for Medicare and Medicaid Services (CMS) Standard Analytic File to identify fee-for-service beneficiaries who had a cancer diagnosis, and had one or more outpatient claims in 2018. We totaled individual claims and costs for ED visits per beneficiary, then calculated mean per-person claims and costs for malnourished vs non-malnourished patients.

RESULTS

Using data from over 2.8 million claims of patients with cancer diagnoses, the prevalence of diagnosed malnutrition was 2.5%. The most common cancer types were genitourinary, hematologic/blood, and breast. Cancer patients with a malnutrition diagnosis, compared to those without, had a significantly higher annual total number of outpatient claims (21.4 vs. 11.5, P<.0001), including a 2.5-fold higher rate of ED visits (1.43 vs. 0.56, p<.0001). As result, such patients incurred more than 2-fold higher mean ED claim costs than did their adequately nourished counterparts ($10,724 vs. $4,935, P<.0001).

CONCLUSIONS

Our results suggest that malnutrition in cancer patients imposes a high outpatient burden on resource utilization and costs of care in terms of ED use. We propose that nutritional interventions can be used to improve health outcomes for people with cancer and to improve economic outcomes for patients and providers.

The prevalence of CT-defined low skeletal muscle mass in patients with metastatic cancer: a cross-sectional multicenter French study (the SCAN study)

Background

Cachexia, characterized by involuntary muscle mass loss, negatively impacts survival outcomes, treatment tolerability, and functionality in cancer patients. However, there is a limited appreciation of the true prevalence of low muscle mass due to inconsistent diagnostic methods and limited oncologist awareness.

Methods

Twenty-nine French healthcare establishments participated in this cross-sectional study, recruiting patients with those metastatic cancers most frequently encountered in routine practice (colon, breast, kidney, lung, prostate). The primary outcome was low skeletal muscle mass prevalence, as diagnosed by estimating the skeletal mass index (SMI) in the middle of the third-lumbar vertebrae (L3) level via computed tomography (CT). Other objectives included an evaluation of nutritional management, physical activity, and toxicities related to ongoing treatment.

Results

Seven hundred sixty-six patients (49.9% males) were enrolled with a mean age of 65.0 years. Low muscle mass prevalence was 69.1%. Only one-third of patients with low skeletal muscle mass were receiving nutritional counselling and only 28.4% were under nutritional management (oral supplements, enteral or parenteral nutrition). Physicians highly underdiagnosed those patients identified with low skeletal muscle mass, as defined by the primary objective, by 74.3% and 44.9% in obese and non-obese patients, respectively. Multivariate analyses revealed a lower risk of low skeletal muscle mass for females (OR: 0.22, P < 0.01) and those without brain metastasis (OR: 0.34, P < 0.01). Low skeletal muscle mass patients were more likely to have delayed treatment administration due to toxicity (11.9% versus 6.8%, P = 0.04).

Conclusions

There is a critical need to raise awareness of low skeletal muscle mass diagnosis among oncologists, and for improvements in nutritional management and physical therapies of cancer patients to curb potential cachexia. This calls for cross-disciplinary collaborations among oncologists, nutritionists, physiotherapists, and radiologists.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-021-06603-0.

Patient and carer experiences of nutrition in cancer care: a mixed-methods study

PURPOSE

Evidence-based guidelines exist to guide health professionals and services about cancer nutrition care; however, the views of cancer patients and carers are not well understood. This study aimed to understand the experience and needs of cancer patients and carers regarding nutrition care across the care continuum.

METHODS

Using a mixed-methods approach, cancer patients and carers completed a cross-sectional online survey and focus groups. Participants were recruited through health services and cancer organisation consumer networks via email distribution lists, e-newsletters, and social media. Focus groups were audio-recorded, transcribed, and analysed using content analysis.

RESULTS

Of 165 survey respondents, only 51% (n=84) reported they talked to a health professional about their nutrition care at any time-point, and only 32% with a dietitian. The majority (84%) of patients and carers felt nutrition was important at one or more time-points in their cancer path, indicating during and after cancer treatment the most important. However, perceived support from health professionals for nutrition care was deemed low at all time-points. Five focus groups were held (n=20; 16 patients, 2 carers, 2 both patients/carers) and five themes emerged: nutrition information, experiences and need; control over diet and nutrition; importance and value of nutrition; access to support; what optimal nutrition care looks like.

CONCLUSION

Patients and carers felt nutrition was important during their cancer path, but perceived support from health professionals for nutrition care was low. This study has highlighted patient and carer nutrition experiences that will inform development of a co-designed optimal cancer nutrition care pathway.

Nutritional Status and Health-Related Quality of Life in Men with Advanced Castrate-Resistant Prostate Cancer

BACKGROUND

Despite professional recommendations malnutrition is not adequately addressed in cancer patients. Here, we explored whether nutritional status (NS) is associated with HRQoL in men with metastatic castrate-resistant prostate cancer (mCRPC). Methods: Men with mCRPC enrolled into this prospective observational study were allocated to one of the four NS categories based on clinical, laboratory, and patient self-reported criteria: well-nourished (WN), nutritional risk without criteria for cachexia/sarcopenia (NR), sarcopenia, and cachexia. The HRQoL was evaluated by the Functional Assessment of Cancer Therapy-Prostate (FACT-P) questionnaire. Association between NS and self-reported HRQoL was sought by the linear regression model, which was adjusted for known prognostic variables and body mass index. Results: Over the period of two years, 141 patients were enrolled. Their median age was 74.1 years (IQR 68.6-79.4 years) and majority of them were minimally symptomatic. Fifty-nine patients (41.8%) were WN, followed by 24 (17%), 42 (29.8%), and 16 (11.4%) patients with NR, sarcopenia, and cachexia, respectively. As compared to WN patients, all three other NS categories were significant negative predictors of HRQoL (P < 0.04). Conclusions: Abnormal NS is highly prevalent in men with mCRPC and is negatively associated with their HRQoL, which supports the recommendation for management of malnutrition in these patients.

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.

New perspective toward nutritional support for malnourished cancer patients: Role of lipids

To improve the difficulties related to malnutrition, nutritional support has become an essential part of multidisciplinary comprehensive treatment for cancer. Lipids are essential nutrient source for the human body, and nowadays in clinical practices, it has a positive interventional effect on patients suffering from cancer. However, contribution of lipids in nutritional support of cancer patients is still poorly understood. Moreover, the sensory and physicochemical properties of lipids can severely restrict their applications in lipid-rich formula foods. In this review article, for the first time, we have presented a summary of the existing studies which were related to the associations between different lipids and improved malnutrition in cancer patients and discussed possible mechanisms. Subsequently, we discussed the challenges and effective solutions during processing of lipids into formula foods. Further, by considering existing problems in current lipid nutritional support, we proposed a novel method for the treatment of malnutrition, including developing individualized lipid nutrition for different patients depending on the individual's genotype and enterotype. Nonetheless, this review study provides a new direction for future research on nutritional support and the development of lipid-rich formula foods for cancer patients, and probably will help to improve the efficacy of lipids in the treatment of cancer malnutrition.

Analysis of Quality of Life and Nutritional Status in Elderly Patients with Dysphagia in Order to Prevent Hospital Admissions in a COVID-19 Pandemic

(1) Background: Oropharyngeal dysphagia (OD) is currently recognized as one of the geriatric syndromes due to its high frequency in older people and its associated complications, which have a direct impact on quality of life. The main objective is to determine the effectiveness of telehealth consultation for the re-evaluation of nutritional status and quality of life assessment in older people diagnosed with OD associated with active use of thickeners to prevent hospital admissions in a COVID-19 pandemic. (2) Methods: an observational, descriptive, and longitudinal study that included a sample of 33 subjects with age equal or superior to 65 years diagnosed with OD with conserved cognitive capacity. The nutritional status was evaluated through the Mini-Nutritional Assessment (MNA) questionnaire and biochemical parameters and, the quality of life was determined through the Swallowing Quality of Life (SWAL-QOL) questionnaire. (3) Results: Thirty-three older patients with OD were recruited (54.5% women), with a mean age of 83.5 ± 7.6 years. The main cause of OD in the study population was neurodegenerative disease (51.5%), followed by cerebrovascular disease (33.3%), and other causes (15.2%). Sixty point six percent of patients were found to be at risk of malnutrition. The MNA score was significantly correlated to albumin (r: 0.600, p < 0.001) and total proteins (r: 0.435, p = 0.015), but not to total cholesterol (r: -0.116, p = 0.534) or lymphocytes (r: -0.056, p = 0.758). The mean total score of the SWAL-QOL was 75.1 ± 16.4 points. (4) Conclusions: the quality of life of the subjects related to the use of a thickener is good. Although the body mass index (BMI) and average biochemical, nutritional parameters of the subjects are within the range of normality, the MNA has detected a high percentage of subjects with the risk of malnutrition, which suggests the need for continuous re-evaluation in these patients, demonstrating the viability of the telematic route in this research.

The prognostic role of prognostic nutritional index in nasopharyngeal carcinoma: A systematic review and meta-analysis

PURPOSE

The prognostic utility of the prognostic nutritional index (PNI) in nasopharyngeal carcinoma (NPC) has never been systematically reviewed. Therefore, we performed this meta-analysis.

METHODS

We performed comprehensive research via Embase, PubMed, Web of Science and the Cochrane Library. The pooled hazard ratios (HRs) and odds ratios (ORs) with 95% confidence intervals (CIs) were applied to explore the relationship between PNI and overall survival (OS), progression-free survival (PFS), locoregional failure-free survival (LRFFS), distant metastasis-free survival (DMFS) and clinical features. Both univariate analysis (UVA) and multivariate analysis (MVA) were used.

RESULTS

A total of 8 eligible studies including 3631 patients were ultimately enrolled. A low PNI level was significantly associated with a shorter OS [(HR 2.06, P < 0.00001; UVA) and (HR 1.78, P < 0.00001; MVA)], PFS [(HR 2.27, P = 0.006; UVA) and (HR 1.45, P = 0.0003; MVA)] and DMFS [(HR 2.06, P < 0.00001; UVA) and (HR 2.04, P < 0.00001; MVA)]. However, only one study reported the LRFFS of NPC patients, and there was no significant difference [HR 1.68, P = 0.26]. Furthermore, female patients, higher tumor stage, a lower alanine transaminase (ALT) level and a lower white blood cell (WBC) level were associated with a lower PNI level.

CONCLUSION

Our meta-analysis indicated that NPC patients with a low PNI level had worse OS, PFS and DMFS, and a low PNI level was associated with female patients, higher tumor stage, a lower ALT level and a lower WBC level. These findings indicate that PNI is a promising prognostic biomarker.

Percutaneous endoscopic gastrostomy – Too often? Too late? Who are the right patients for gastrostomy?

Percutaneous endoscopic gastrostomy is an established method to provide nutrition to patients with restricted oral uptake of fluids and calories. Here, we review the methods, indications and complications of this procedure. While gastrostomy can be safely and easily performed during gastroscopy, the right patients and timing for this intervention are not always chosen. Especially in patients with dementia, the indication for and timing of gastrostomies are often improper. In this patient group, clear data for enteral nutrition are lacking; however, some evidence suggests that patients with advanced dementia do not benefit, whereas patients with mild to moderate dementia might benefit from early enteral nutrition. Additionally, other patient groups with temporary or permanent restriction of oral uptake might be a useful target population for early enteral nutrition to maintain mobilization and muscle strength. We plead for a coordinated study program for these patient groups to identify suitable patients and the best timing for tube implantation.

GNRI as a Prognostic Factor for Outcomes in Cancer Patients: A Systematic Review of the Literature

Oncologic patients often suffer from malnutrition which in turn, might have negative impact on treatment outcomes. The Geriatric Nutritional Risk Index (GNRI), as an index of impaired nutritional status, has emerged as a significant prognostic factor for short-and long-term outcomes in cancer patients. The aim of the current systematic review is to determine whether the GNRI is an independent prognostic factor of postoperative complications and survival in cancer patients. A systematic search was conducted to identify studies, published from 2005 to 2019, which assessed associations between GNRI and short- and long-term outcomes in cancer patients. Eighteen studies fulfilled the eligibility criteria and were included in the analysis. Low scores of GNRI were associated with increased risk for developing postoperative complications and impaired survival of cancer patients in most studies. Our findings support the use of the GNRI in the clinical practice, since it is a simple and reliable tool for assessing nutritional status in oncologic patients. More prospective, multi-centered studies are warranted to confirm the current results, as well as the role of nutritional support in improving the prognosis of cancer patients.

Unmet needs in clinical nutrition in oncology: a multinational analysis of real-world evidence

BACKGROUND

Knowledge about cancer-related malnutrition and the use of clinical nutrition (CN) in the real-world setting are lacking. We investigated diagnosis and treatment frequency of malnutrition in a multinational survey to identify unmet needs in cancer patients' care.

METHODS

Retrospective analyses were conducted on data from three administrative healthcare datasets from France (n = 570,727), Germany (n = 4642) and Italy (n = 58,468). Data from France described frequency and timing of malnutrition diagnosis in hospitalized gastrointestinal cancer patients. The German data detailed home parenteral nutrition (HPN) use in cancer patients with stage III/IV cancers. The Italian data analysed three cohorts: metastatic with CN, metastatic without CN, and patients without metastatic disease.

RESULTS

In France, malnutrition diagnosis at first hospitalization occurred in 10% of patients, 13% were subsequently diagnosed, and 77% had no malnutrition diagnosis. In Germany, 16% of patients received HPN. Patients started HPN around 3 months before death. In Italy, 8.4% of metastatic cancer patients received CN; average time between metastasis diagnosis and first CN prescription was 6.6 months. Average time between first CN prescription and death was 3.5 months.

CONCLUSIONS

These data indicate that in the real-world clinical practice, cancer-related malnutrition is under-recognized and undertreated. CN often appears to be prescribed as an end-of-life intervention or is not prescribed at all.Appropriate CN use remains challenging, and current practice may not allow optimal oncologic outcomes for patients at nutritional risk. Improving awareness of malnutrition and generating further evidence on clinical and economic benefits of CN are critical priorities in oncology.

Psychological distress and nutritional status in head and neck cancer patients: a pilot study

Purpose

To determine whether the psychological state of patients with head and neck cancer (HCN) is associated with their nutritional status.

Methods

In 40 patients with locally advanced HNC treated with definitive or adjuvant (chemo)radiotherapy, psychological and nutritional status were assessed before treatment, at its completion and 3 months’ post-therapy. Psychosocial distress was measured using the Hospital Anxiety and Depression Scale questionnaire (HADS-A, HADS-D), whereas the nutritional status was evaluated using standard methods (Nutritional Risk Screening Tool 2002, anthropometric data, dynamometry and laboratory tests) and with a bioelectrical impedance analysis parameter phase angle (PA).

Results

Before treatment, more patients were screened positive for anxiety than at treatment completion (p = 0.037) or 3 months’ post-therapy (p = 0.083). Depression prevalence was non-significantly higher at the end and after therapy. Compared to the baseline, more cachectic patients and a reduction of PA values were found at successive assessments. Anxiety was more often recorded among malnourished/cachectic patients (assessment 1, p = 0.017; assessment 2, p = 0.020) who were also found more frequently depressed (assessment 2, p = 0.045; assessment 3, p = 0.023). Significantly higher PA values were measured in patients without distress determined at 3 months’ post-therapy by the HADS-A (p = 0.027).

Conclusion

The association between the psychological and nutritional status found in this pilot study and the options for intervention warrants further clarification in a larger prospective trial.

Systematic nutrition management for locally advanced nasopharyngeal carcinoma patients undergoing radiotherapy

Objective

To evaluate the impact of systematic nutrition management (SNM) on nutritional status, treatment-related toxicity, quality of life (QoL), response rates, and survival in patients with locally advanced nasopharyngeal carcinoma (LA-NPC) treated by radiotherapy (RT).

Methods

In this retrospective study, 56 patients with LA-NPC were selected as nutrition management group (NG) for SNM during RT till 1 month later. Another 56 patients with LA-NPC receiving RT without SNM as control group (CG) were identified from the hospital database and matched pairs with NG patients according to age, gender, stage, and body mass index (BMI) prior to RT.

Results

At 1 month after RT, the percentage of malnourished patients with BMI <18.5 kg/m² was statistically significant reduced in NG as compared to the CG group (35.7% vs 58.9%, P=0.014). Nutritional indexes of body weight, hemoglobin, prealbumin, and lymphocyte in the NG were statistically significant higher than those in the CG group (P<0.05). NG patients had statistically significant less grade 3–4 oral mucositis during RT compared with the CG group (32.1% vs 51.8%, P=0.035). Furthermore, at 1 month after RT, an improved QoL was observed in NG patients with respect to physical, role and social functions, symptom scales of fatigue and pain, and the global health status as compared to the CG group (P<0.05). With a median follow-up of 24.8 months, there were no statistical differences between NG and CG (P>0.05) for the 2-year progression-free survival and overall survival (84.2% versus 79.5% and 94.7% versus 92.3%, respectively.).

Conclusion

SNM for LA-NPC patients treated by RT resulted in better nutritional status, reduced treatment-related toxicity and improved QoL.

Chemosensory Changes from Cancer Treatment and Their Effects on Patients' Food Behavior: A Scoping Review

Individuals undergoing treatment for cancer can experience changes in taste or smell that are often assumed to affect constructs related to food behavior, although this relationship is rarely measured directly. To ascertain the extent to which measured changes in taste and smell during and after cancer treatment affect food behavior, we conducted a scoping review and completed a comparative analysis for studies that met our criteria, which were: they directly measured cancer patients’ (a) psychophysical response to taste and/or olfactory stimuli, and (b) food behavior (including food enjoyment, food preference, dietary intake) in people affected by cancer. Eleven studies met these criteria and were included in the review. All 11 studies evaluated taste and five also measured smell. A comparative analysis exploring taste and food behavior shows that a reduced sweet taste function (decreased sensitivity) was associated with a reduced intake of a variety of different macro and micro nutrients, reduced appetite, and overall lower energy intake. One out of six studies that measured smell and food measured observed changes in olfactory function following cancer treatment. There were no significant relationships reported between olfactory measures and food behavior. Taste changes that arise from cancer treatment appear to have a direct effect on food behavior, although there is a need for more research using standardized measures and larger sample sizes. A better understanding of taste alterations and their implications for dietary intake and food enjoyment will support optimal nutritional health by identifying strategies to help patients eat well during and after cancer treatment.

Adverse impact of malnutrition markers on major abdominopelvic cancer surgery

BACKGROUND

Malnutrition has been associated with adverse postoperative outcomes in a range of procedures but none have evaluated the interaction between clinical indicators of malnutrition. We aimed to comparatively evaluate how combinations of nutritional parameters impact postoperative outcomes amongst patients undergoing major cancer operations.

METHODS

Major abdominopelvic cancer surgery cases (colectomy, cystectomy, esophagectomy, gastrectomy, hysterectomy, nephrectomy, pancreatectomy, pneumonectomy and prostatectomy) were identified in the American College of Surgeons National Surgical Quality Improvement Program database from 2007-2016. Malnutrition was defined by the presence of the following parameters: body mass index <18.5 kg/m² ; preoperative serum albumin <3.0 g/dL or more than 10% weight loss in the last 6 months. Malnourished cases were matched with cases with satisfactory nutritional status using propensity scores. The primary outcome was the incidence of Clavien III-IV complications.

RESULTS

Of the 30 207 cases included, 8.5% had at least one marker of malnutrition. The incidence of Clavien III-IV complications across all cases was 5.8%. In the matched cohort, malnourished cases had a higher rate of complications than those with adequate nutritional status (11.3% versus 9.6%, P = 0.018). A correlation was observed between the number of malnutrition markers possessed and the incidence of Clavien III-V complications. Cases with all three makers had the highest likelihood of experiencing a complication (odds ratio 5.47, 95% confidence interval 1.85-16.17).

CONCLUSION

Poor nutritional status confers an increased risk of major postoperative complications and being discharged to a facility in non-upper gastrointestinal cancer patients. There was a correlation between the number of malnutrition parameters and the risk of complications.

Computed tomography-quantified body composition predicts short-term outcomes after gastrectomy in gastric cancer

Background

Malnutrition is a common and critical problem that influences outcome in cancer patients. Body composition reflects a patient's metabolic profile and physiologic reserves, which might be the true determinant of prognosis. In the present study, which aimed to identify valuable new prognostic indicators, we investigated the association between computed tomography-quantified body composition and short-term outcomes after gastrectomy for gastric cancer.

Methods

Skeletal muscle index, mean muscle attenuation, and ratio of visceral-to-subcutaneous adipose tissue area (vsr) were calculated from preoperative computed tomography images. Low skeletal muscle index, low mean muscle attenuation, and high vsr were respectively termed "sarcopenia," "myosteatosis," and "visceral obesity." The association of body composition with postoperative complications and serum markers of nutrition and inflammation after radical gastrectomy were analyzed.

Results

The overall complication rate was significantly higher in the sarcopenia (62.5% vs. 27.3%, p = 0.001) and myosteatosis groups (38.2% vs. 4%, p = 0.002). Patients with visceral obesity had a higher incidence of inflammatory complications (20.3% vs. 6.5%, p = 0.01). Multivariate logistic regression analysis demonstrated that sarcopenia (p = 0.013), myosteatosis (p = 0.017), and low serum retinol-binding protein (p = 0.019) were independent risk factors for overall complications. Compared with control subjects, patients with sarcopenia had lower postoperative levels of serum retinol-binding protein (p = 0.007), and patients with visceral obesity had higher levels of C-reactive protein (p = 0.026).

Conclusions

Sarcopenia, myosteatosis, and visceral obesity were significantly associated with increased rates of postoperative complications and affected the postoperative nutrition and inflammation status of patients with gastric cancer.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Is continuing medical education sufficient? Assessing the clinical nutrition knowledge of medical doctors

OBJECTIVES

Provision of nutritional support (NS) can improve disease outcome and shorten hospital length of stay. NS, often prescribed by medical doctors, requires adequate clinical nutrition (CN) expertise. The aim of this study was to investigate self-perceived and actual CN knowledge among medical doctors in Greece.

METHODS

Internal medicine physicians and surgical specialties (residents and specialized) were asked to self-evaluate their CN expertise, via a seven-item questionnaire and to complete a 20-question multiple-choice test on CN topics, with the aim of evaluating their actual CN knowledge. Participants were discouraged from accessing literature/information during the completion of either questionnaire.

RESULTS

Of 182 invited medical doctors, 115 (50.4% surgical specialties) participated in the study (63.2% response rate). The majority of participants (65.2%) demonstrated inadequate CN knowledge, with 30.4% of those scoring low having a high self-perception of their CN expertise. Comparison of perceived and actual CN knowledge revealed that only 56.5% of the participants estimated their knowledge correctly. Those who had participated in CN continuous medical education courses demonstrated increased related expertise (P = 0.002).

CONCLUSIONS

Medical doctors in Greece demonstrate low knowledge of fundamental CN principles, jeopardizing the provision of high-quality and efficient NS. Most importantly, the majority of participants overestimated their CN knowledge and prescribe artificial nutrition or participate in related decision making. Physicians' CN knowledge should be enhanced accordingly, either by attending CN modules during their studies, by participating in basic and advanced courses or CN-specific continuous medical education, or both.

Systematic review and meta-analysis of the evidence for oral nutritional intervention on nutritional and clinical outcomes during chemo(radio)therapy: current evidence and guidance for design of future trials

Background

Driven by reduced nutritional intakes and metabolic alterations, malnutrition in cancer patients adversely affects quality of life, treatment tolerance and survival. We examined evidence for oral nutritional interventions during chemo(radio)therapy.

Design

We carried out a systematic review of randomized controlled trials (RCT) with either dietary counseling (DC), high-energy oral nutritional supplements (ONS) aiming at improving intakes or ONS enriched with protein and n-3 polyunsaturated fatty acids (PUFA) additionally aiming for modulation of cancer-related metabolic alterations. Meta-analyses were carried out on body weight (BW) response to nutritional interventions, with subgroup analyses for DC and/or high-energy ONS or high-protein n-3 PUFA-enriched ONS.

Results

Eleven studies were identified. Meta-analysis showed overall benefit of interventions on BW during chemo(radio)therapy (+1.31 kg, 95% CI 0.24-2.38, P = 0.02, heterogeneity Q = 21.1, P = 0.007). Subgroup analysis showed no effect of DC and/or high-energy ONS (+0.80 kg, 95% CI -1.14 to 2.74, P = 0.32; Q = 10.5, P = 0.03), possibly due to limited compliance and intakes falling short of intake goals. A significant effect was observed for high-protein n-3 PUFA-enriched intervention compared with isocaloric controls (+1.89 kg, 95% CI 0.51-3.27, P = 0.02; Q = 3.1 P = 0.37). High-protein, n-3 PUFA-enriched ONS studies showed attenuation of lean body mass loss (N = 2 studies) and improvement of some quality of life domains (N = 3 studies). Overall, studies were limited in number, heterogeneous, and inadequately powered to show effects on treatment toxicity or survival.

Conclusion

This systematic review suggests an overall positive effect of nutritional interventions during chemo(radio)therapy on BW. Subgroup analyses showed effects were driven by high-protein n-3 PUFA-enriched ONS, suggesting the benefit of targeting metabolic alterations. DC and/or high-energy ONS were less effective, likely due to cumulative caloric deficits despite interventions. We highlight the need and provide recommendations for well-designed RCT to determine the effect of nutritional interventions on clinical outcomes, with specific focus on reaching nutritional goals and providing the right nutrients, as part of an integral supportive care approach.

ESPEN expert group recommendations for action against cancer-related malnutrition

Patients with cancer are at particularly high risk for malnutrition because both the disease and its treatments threaten their nutritional status. Yet cancer-related nutritional risk is sometimes overlooked or under-treated by clinicians, patients, and their families. The European Society for Clinical Nutrition and Metabolism (ESPEN) recently published evidence-based guidelines for nutritional care in patients with cancer. In further support of these guidelines, an ESPEN oncology expert group met for a Cancer and Nutrition Workshop in Berlin on October 24 and 25, 2016. The group examined the causes and consequences of cancer-related malnutrition, reviewed treatment approaches currently available, and built the rationale and impetus for clinicians involved with care of patients with cancer to take actions that facilitate nutrition support in practice. The content of this position paper is based on presentations and discussions at the Berlin meeting. The expert group emphasized 3 key steps to update nutritional care for people with cancer: (1) screen all patients with cancer for nutritional risk early in the course of their care, regardless of body mass index and weight history; (2) expand nutrition-related assessment practices to include measures of anorexia, body composition, inflammatory biomarkers, resting energy expenditure, and physical function; (3) use multimodal nutritional interventions with individualized plans, including care focused on increasing nutritional intake, lessening inflammation and hypermetabolic stress, and increasing physical activity.