Nutrition in Cancer Patients

Predictive value of prognostic nutritional index for outcomes of cervical cancer: A systematic review and meta‑analysis

Cervical cancer is a major global health concern. Prognostic markers for cervical cancer have traditionally focused on tumor characteristics. However, there is a growing recognition of the importaxnce of the nutritional status of the patient as a possible prognostic indicator. The present meta-analysis aims to estimate the role of the prognostic nutritional index (PNI) in predicting overall survival (OS) and progression-free survival (PFS) in patients with cervical cancer. Medline, Google Scholar, Science Direct and Cochrane Central databases were systematically searched for studies reporting PNI in patients with cervical cancer. Inclusion criteria were applied to select relevant studies and data extraction was performed by two independent investigators. Risk of bias was assessed by the Newcastle-Ottawa Scale (NOS). The present meta-analysis included 10 studies with 2,352 participants. The pooled analysis showed that in patients with cervical cancer PNI did not have a significant prognostic utility in predicting OS [univariate hazard ration (HR): 1.38; 95% confidence interval (CI): 0.77-2.48) or PFS (univariate HR: 1.12; 95% CI: 0.44-2.68). These results were consistent even after adjusting for other confounders using multivariate analysis (pooled HR: 1.06 for OS; 95% CI: 0.64-1.76; pooled HR: 1.22 for PFS; 95% CI: 0.65-2.30). Subgroup analyses were also performed based on region, PNI cut-off, sample size, grade of evidence and treatment protocol and did not demonstrate any significant prognostic value of PNI. The funnel plot demonstrated symmetry, suggesting the absence of publication bias. The present meta-analysis indicated that PNI does not have a significant prognostic utility in predicting OS or PFS in women with cervical cancer. Further research is warranted to explore alternative nutritional indicators and identify reliable prognostic markers in this patient population.

A nomogram combining neutrophil to lymphocyte ratio (NLR) and prognostic nutritional index (PNI) to predict distant metastasis in gastric cancer

In this study, We aim to explore the association between the neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), systemic immune-inflammatory index (SII), lymphocyte to monocyte ratio (LMR) and prognostic nutritional index (PNI) and distant metastasis of gastric cancer and develop an efficient nomogram for screening patients with distant metastasis. A total of 1281 inpatients with gastric cancer were enrolled and divided into the training and validation set.Univariate, Lasso regression and Multivariate Logistic Regression Analysis was used to identify the risk factors of distant metastasis. The independent predictive factors were then enrolled in the nomogram model. The nomogram's predictive perform and clinical practicality was evaluated by receiver operating characteristics (ROC) curves, calibration curves and decision curve analysis. Multivariate Logistic Regression Analysis identified D-dimer, CA199, CA125, NLR and PNI as independent predictive factors. The area under the curve of our nomogram based on these factors was 0.838 in the training cohort and 0.811 in the validation cohort. The calibration plots and decision curves demonstrated the nomogram's good predictive performance and clinical practicality in both training and validation cohort. Therefore,our nomogram could be an important tool for clinicians in screening gastric cancer patients with distant metastasis.

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.

Comparison of the Efficacy of Indwelling Gastric Tubes in Preoperative and Postoperative Patients With Oral and Maxillofacial Malignancies

PURPOSE

To explore the optimal plan for the timing of indwelling gastric tube placement in oral and maxillofacial malignant tumor patients.

DESIGN

A prospective randomized controlled trial.

METHODS

80 patients with oral and maxillofacial tumor were selected, and 40 patients were Pre-operative group. The remaining 40 patients were the control group, called Postoperative group. The body weight and hospital stay of the two groups were observed before and after surgery. Blood samples were taken before surgery and 1, 3 and 7 days after surgery to detect hemoglobin and plasma albumin.

FINDINGS

The number of postoperative hospitalization days in the pre-operative group was significantly lower than that in the post-operative group; postoperative hemoglobin and plasma albumins were lower in both groups compared with the preoperative level.

CONCLUSIONS

Preoperative nasogastric tube ensured early postoperative administration of gastrointestinal nutrition, promoted postoperative plasma albumin recovery, and shortened the days of hospitalization.

Effect of a multimodal intervention in breast Cancer patients undergoing neoadjuvant therapy: A study protocol of the multimodal project

BACKGROUND AND AIMS

To determine the effect of a multimodal intervention (nutritional behavior change and physical exercise) on quality of life, chemotherapy response rate and tolerance, histopathological level of the tumor, body composition, and biochemical parameters, in patients diagnosed with breast cancer during neoadjuvant chemotherapy treatment, and to compare them with the control group.

METHODS

Anticipated 80 patients diagnosed with breast cancer aged 18-70 years will be recruited for this randomized, unblinded clinical trial based on a nutritional behavior change and physical exercise in patients during the approximately 6 months in which the patient receives neoadjuvant treatment. Participants will be randomly allocated (1:1) to one of two groups (intervention or control). Primary and secondary outcomes will be assessed before the beginning and after the neoadjuvant treatment (before surgery). The primary outcome is quality of life, whereas secondary outcomes include chemotherapy response rate and tolerance, histopathological level of the tumor and body composition (i.e., visceral adipose tissue activity, bone, lean and fat masses). We will analyze blood parameters (i.e., biochemical, inflammatory, and tumor markers) as exploratory outcomes.

CONCLUSION

This study will address the influence of a practical and viable multimodal intervention (i.e., nutritional behavior change and physical exercise) on breast cancer patients undergoing neoadjuvant chemotherapy. Given the practical viability of the intervention in real-world settings, our study holds promise for significant scientific and clinical implications.

Prognostic impact of muscle mass loss in elderly patients with oesophageal cancer receiving neoadjuvant chemoradiation therapy

BACKGROUND

We aimed to identify the impact of muscle mass on locally advanced oesophageal cancer (LAEC) in elderly patients receiving neoadjuvant chemoradiation therapy (NACRT).

METHODS

We reviewed the medical records of 345 patients diagnosed with LAEC who underwent NACRT and surgery. Physical variables, including height, weight, skeletal muscle mass, and laboratory values, were obtained before and after NACRT. Body mass index (BMI, kg/m2), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and prognostic nutritional index (PNI) were calculated as height/(weight)2, ANC/ALC, platelet count/ALC, and (10 × albumin + 0.05 × ALC), respectively. The cutoff for low muscle mass was 43.0 cm2/m2 for BMI below 25 kg/m2 and 53.0 cm2/m2 for BMI 25 kg/m2 or higher. The skeletal muscle index (SMI) was defined as skeletal muscle area/(height)2 (cm2/m2). The ΔSMI (%/50 days) was defined as (SMI after NACRT - SMI before NACRT)/interval (days) × 50 (days) to compare changes over the same period. The excessive muscle loss (EML) group was defined as patients with ΔSMI ≤-10% following NACRT. An elderly patient was defined as aged ≥65 years. The primary outcome measure was overall survival (OS).

RESULTS

During a median follow-up of 32.8 months (range, 2.0-176.2), 192 patients died, with a median OS of 50.2 months. Elderly patients did not show inferior OS (young vs. elderly, 57.7% vs. 54.0% at 3 years, P = 0.247). 71.0% and 87.2% of all patients had low muscle mass before and after NACRT, respectively, which was not associated with OS (P = 0.270 and P = 0.509, respectively). Inflammatory (NLR and PLR) and nutritional index (PNI) values or their changes did not correlate with OS. However, the EML group had worse OS (41.6% vs. 63.2% at 3 years, P < 0.0001). In the multivariate analysis, EML was also a significant prognostic factor for OS. In the subgroup analysis by age, EML was a strong prognostic factor for OS in the elderly group. The 3-year OS was 36.8% in the EML group and 64.9% in the non-EML group (P < 0.0001) in elderly patients, and 47.4% and 62.1% (P = 0.063) in the young patients. In multivariate analysis of each subgroup, EML remained prognostic only in the elderly group (P = 0.008).

CONCLUSIONS

EML may be strongly associated with a deteriorated OS in elderly patients undergoing NACRT, followed by surgery for LAEC. The strategies for decreasing muscle loss in these patients should be investigated.

National Implementation of an Artificial Intelligence-Based Virtual Dietitian for Patients With Cancer

PURPOSE

Nutritional status is an established driver of cancer outcomes, but there is an insufficient workforce of registered dietitians to meet patient needs for nutritional counseling. Artificial intelligence (AI) and machine learning (ML) afford the opportunity to expand access to guideline-based nutritional support.

METHODS

An AI-based nutrition assistant called Ina was developed on the basis of a learning data set of >100,000 expert-curated interventions, peer-reviewed literature, and clinical guidelines, and provides a conversational text message-based patient interface to guide dietary habits and answer questions. Ina was implemented nationally in partnership with 25 advocacy organizations. Data on demographics, patient-reported outcomes, and utilization were systematically collected.

RESULTS

Between July 2019 and August 2023, 3,310 users from all 50 states registered to use Ina. Users were 73% female; median age was 57 (range, 18-91) years; most common cancer types were genitourinary (22%), breast (21%), gynecologic (19%), GI (14%), and lung (12%). Users were medically complex, with 50% reporting Stage III to IV disease, 37% with metastases, and 50% with 2+ chronic conditions. Nutritional challenges were highly prevalent: 58% had overweight/obese BMIs, 83% reported barriers to good nutrition, and 42% had food allergies/intolerances. Levels of engagement were high: 68% texted questions to Ina; 79% completed surveys; median user retention was 8.8 months; 94% were satisfied with the platform; and 98% found the guidance helpful. In an evaluation of outcomes, 84% used the advice to guide diet; 47% used recommended recipes, 82% felt the program improved quality of life (QoL), and 88% reported improved symptom management.

CONCLUSION

Implementation of an evidence-based AI virtual dietitian is feasible and is reported by patients to be beneficial on diet, QoL, and symptom management. Ongoing evaluations are assessing impact on other outcomes.

Nutritional Prehabilitation in Patients Undergoing Cystectomy: A Systematic Review

BACKGROUND/AIM

Nutrition is a key element of the prehabilitation process prior to surgery. The aim of this study was to identify the clinical pathways of nutritional prehabilitation before cystectomy.

METHODS

A systematic literature review was conducted in PubMed, the Cochrane Library, CINAHL, Scopus and the Web of Science databases. Quality and risk of bias assessment was conducted adhering to the JBI framework and evidence was evaluated according to the Oxford Centre for Evidence Based Medicine levels of evidence.

RESULTS

Out of 586 records identified, six studies were included. Among them, only two were randomized controlled trials. Immunonutrition has been shown to improve postoperative bowel function (3.12 vs. 3.74 days; RR 0.82; CI, 0.73-0.93; p = 0.0029) and decrease postoperative complications (-36.7%; p = 0.008) and readmission rates (-15.38%; p = 0.03). Furthermore, oral nutritional supplements combined with nutritional counseling demonstrated an accelerated recovery of bowel function (-1 day; p < 0.01), a reduction in the length of hospital stay (-1.75 days; p = 0.01), an improvement in handgrip strength (+6.8%, p < 0.001), an increase in bone mass (+0.3 kg, p = 0.04), and a better BMI value (+2.3%, p = 0.001).

CONCLUSIONS

Nutritional prehabilitation demonstrates potential in enhancing postoperative outcomes following radical cystectomy. Oral supplements, immunonutrition, and counseling exhibit efficacy in improving postoperative results.

Risk Factors for Unplanned Early Implantable Port Catheter Removal in Adult Hematology Cancer Patients Receiving Chemotherapy: A Propensity Score Matching Study

Purpose

Implantable port catheter is a reliable vascular access for chemotherapy infusion in cancer patients. However, patients with hematology malignancies usually present with a myriad of blood cell abnormalities that put them at risk of infection and mechanical problems requiring catheter removal. This study aims to determine the risk factors associated with unplanned (catheter removal other than completion of treatment plan) early (within 90 days of catheter implantation) implantable port catheter removal.

Patients and Methods

A retrospective, propensity score-matched study of 386 patients with hematology malignancies who received implantable venous access ports between January 2015 and December 2022. We conducted a univariate analysis to select the variables for propensity score matching. Patients with unplanned early implantable port catheter removal (early group) were matched 1:1 to patients without unplanned early removal (non-early group).

Results

Univariate analysis demonstrated a statistically significant difference between early and non-early groups for age (p = 0.048), hemoglobin level (p = 0.028), thrombocytopenia (p = 0.025), and PG-SGA (p < 0.001). Thrombocytopenia was the only independent risk factor with a statistically significant difference in Cox proportional hazard analysis, HR 2.823, 95 CI 1.050-7.589, p = 0.040. The median catheter survival for patients with thrombocytopenia was 61 days (95% CI 28.58-93.42) compared to 150 days (95% CI 9.81-290.19) for patients without thrombocytopenia, p = 0.015. Patient survival is not affected by early catheter removal. The median survival for patients in the early group was 28.28 months (95% CI 27.43-29.15) compared to 32.39 months (95% CI 24.11-40.68), for the non-early group, p = 0.709.

Conclusion

Hematology malignancy patients with thrombocytopenia are at high risk for unplanned early port catheter removal without survival difference.

Effectiveness of dietetic care for cancer survivors in the primary care setting: A systematic review and meta-analysis of randomized controlled trials

PURPOSE

Nutrition plays an important role in cancer survivorship. This systematic review and meta-analysis aim to critically assess and quantify the effectiveness of nutrition care interventions provided by dietitians to survivors who have completed treatment for cancer.

METHODS

A systematic review of randomized controlled trials (RCTs) published from January 2004 to November 2023 reporting the effectiveness of primary care dietetic interventions with adult cancer survivors was conducted. PubMed, Scopus, CINAHL, Embase, ProQuest and PsycINFO databases were searched for key terms. Meta-analyses were conducted where there were sufficient studies of the same cancer type and outcomes.

RESULTS

Twelve RCTs representing 1138 cancer survivors (519 breast cancer; 75 prostate cancer; 544 colorectal cancer) were included. Primary outcome measures included weight loss (n = 6), quality of life (n = 2), reducing lymphedema-related arm volume (n = 2), nutritional status (n = 1) and increasing fruit and vegetable intake (n = 1). Weight loss was observed in studies where this was the primary outcome. Results for quality of life varied. Meta-analyses of RCTs with breast cancer survivors showed that dietitian intervention achieved a mean of 3.7 kg greater intentional weight loss and 2.3% greater body fat decrease than control (p < 0.0001).

CONCLUSIONS

This study provides evidence for the effectiveness of primary care dietetic interventions by dietitians with cancer survivors, particularly with respect to intentional weight and fat loss in breast cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

Dietitians can play a key role in managing weight and improving long term health outcomes and prognosis for cancer survivors beyond the acute care setting.

Exploring dietary changes and supplement use among cancer patients in Norway: prevalence, motivations, disclosure, information, and perceived risks and benefits: a cross sectional study

BACKGROUND

Cancer is the leading cause of death in Norway, with prostate, breast, lung, and colon cancers being the most prevalent types. Adopting a healthy and varied diet can help reduce cancer risk and recurrence. However, access to dietary counselling remains limited for cancer patients in Norway. This study aimed to investigate the prevalence of dietary supplement use and dietary changes made by cancer patients and survivors. Additionally, it sought to explore the reason(s) for such practices, communication with healthcare providers, sources of information, and reported benefits and potential harms resulting from these changes and supplement use.

METHODS

Conducted in collaboration with the Norwegian Cancer Society (NCS), this online cross-sectional study targeted members of their user panel who had either current or previous cancer (n = 706). The study took place in September/October 2021, utilizing a modified cancer-specific version of the International Questionnaire to Measure Use of Complementary and Alternative Medicine (I-CAM-Q). Out of 468 participants (315 women and 153 men), 67.2% consented to participate. Between-group analyses were conducted using Pearson chi-square tests and Fisher exact tests for categorical variables, while independent sample t-tests were applied for continuous variables.

RESULTS

The majority of the participants (97%) reported making changes to their diet (78%) and/or incorporating dietary supplements (73%) in response to their cancer diagnosis. The primary goal of these changes was to strengthen their body and immune system. Almost half of the participants (49%) reported that they found these changes beneficial and discussed them openly with their healthcare providers, with family physicians being the most common point of discussion (25%). Adverse effects were reported by only a few participants, mostly mild. Information about dietary changes and supplements was primarily sourced from the internet or healthcare providers.

CONCLUSIONS

This study highlights that most individuals affected by cancer attribute to dietary adjustment. It also emphasizes the importance of addressing adherence to dietary recommendations and using reliable sources of information. Additionally, the study highlights the potential, yet currently underutilized, role of healthcare professionals in initiating dialogues about dietary interventions to address any unmet needs of patients. Such proactive engagement may contribute to the promotion of reliable sources of information and the prevention of non-evidence-based and potentially harmful diets or supplement adoption.

Accelerated Aging in Cancer Survivors: Cellular Senescence, Frailty, and Possible Opportunities for Interventions

The population of cancer survivors has markedly increased due to the rapid improvements in cancer treatment. However, cancer survivors experience accelerated aging, which leads to chronic diseases and other age-related conditions, such as frailty. Those conditions may persist years after cancer diagnosis and treatment. Cellular senescence, a hallmark of aging, is one of the mechanisms that contribute to accelerated aging in cancer survivors. Several aging measures, including measures based on clinical markers and biomarkers, have been proposed to estimate the aging process, and some of them have shown associations with mortality and frailty in cancer survivors. Several anti-aging interventions, including lifestyle changes and anti-aging drugs, have been proposed. Future research, particularly in large-scale studies, is needed to determine the efficiency of these aging measures and anti-aging interventions before considering their application in clinics. This review focuses on the mechanisms of cellular senescence and accelerated aging in cancer survivors, assessment of the aging process using clinical markers and biomarkers, and the high prevalence of frailty in that population, as well as possible opportunities for anti-aging interventions. A deeper understanding of aging measures and anti-aging interventions in cancer survivors will contribute to the development of effective strategies to mitigate accelerated aging in cancer survivors and improve their quality of life.

Examining the relationship between nutritional status and wound healing in head and neck cancer treatment: A focus on malnutrition and nutrient deficiencies

The research was conducted to examine the correlation between nutritional status and wound healing in individuals who were receiving treatment for head and neck cancer. Specifically, this study sought to identify crucial nutritional factors that influenced both the recovery process and efficacy of the treatment. From February 2022 to September 2023, this cross-sectional study was undertaken involving 300 patients diagnosed with head and neck cancer who were treated at Tianjin Medical University Cancer Institute and Hospital, Tianjin, China. In order to evaluate nutritional status, body mass index (BMI), serum protein levels and dietary intake records were utilized. The assessment of wound healing was conducted using established oncological wound healing scales, photographic documentation and clinical examinations. After treatment, we observed a noteworthy reduction in both BMI (p < 0.05) and serum albumin levels (p < 0.05). There was slightly increased prevalence of head and neck cancer among males (61.0%, p < 0.05). Over the course of 6 months, significant enhancement in wound healing scores was noted, exhibiting overall improvement of 86% in the healing process. An inverse correlation was identified between nutritional status and wound healing efficacy through multivariate analysis. A logistic regression analysis revealed a significant positive correlation (p < 0.05) between elevated levels of serum protein and total lymphocytes and enhanced wound healing. Conversely, negative correlation (p < 0.05) was observed between larger wound size at baseline and healing. The research findings indicated noteworthy association between malnutrition and impaired wound repair among individuals diagnosed with head and neck cancer. The results underscored the significance of integrating nutritional interventions into therapeutic protocol in order to enhance clinical results. This research study provided significant contributions to the knowledge of intricate nature of head and neck cancer management by advocating for multidisciplinary approach that incorporates nutrition as the critical element of patient care and highlighted the importance of ongoing surveillance and customized dietary approaches in order to optimize wound healing and treatment efficacy.

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.

Obesity and Cancer Rehabilitation for Functional Recovery and Quality of Life in Breast Cancer Survivors: A Comprehensive Review

Obesity is a global health challenge with increasing prevalence, and its intricate relationship with cancer has become a critical concern in cancer care. As a result, understanding the multifactorial connections between obesity and breast cancer is imperative for risk stratification, tailored screening, and rehabilitation treatment planning to address long-term survivorship issues. The review follows the SANRA quality criteria and includes an extensive literature search conducted in PubMed/Medline, Web of Science, and Scopus. The biological basis linking obesity and cancer involves complex interactions in adipose tissue and the tumor microenvironment. Various mechanisms, such as hormonal alterations, chronic inflammation, immune system modulation, and mitochondrial dysfunction, contribute to cancer development. The review underlines the importance of comprehensive oncologic rehabilitation, including physical, psychological, and nutritional aspects. Cancer rehabilitation plays a crucial role in managing obesity-related symptoms, offering interventions for physical impairments, pain management, and lymphatic disorders, and improving both physical and psychological well-being. Personalized and technology-driven approaches hold promise for optimizing rehabilitation effectiveness and improving long-term outcomes for obese cancer patients. The comprehensive insights provided in this review contribute to the evolving landscape of cancer care, emphasizing the importance of tailored rehabilitation in optimizing the well-being of obese cancer patients.

Is virtual nutritional counseling efficacious for cancer patients during the COVID-19 pandemic?

This study investigates the outcomes of virtual nutritional counseling (VNC) for oncology patients during the Covid-19 pandemic. Our study evaluated the nutritional status data of cancer patients at the baseline and after VNC. An oncology dietitian evaluated the patients by video calling each patient via WhatsApp and sent an individual nutrition diet plan and recommendations via e-mail. Patient-Generated Subjective Global Assessment (PG-SGA) was used as a screening and evaluation tool to assess nutritional status. A total of 157 patients with a mean age of 55.8 ± 14.7 (r = 19-89) were included in the study. Researchers detected at least one nutrition-related sign in 77.7% of patients. After the VNC and based on the final PG-SGA assessments, 62.2% of the patients whose baseline PG-SGA Score-B improved to Score-A, 12.5% with a baseline PG-SGA Score-C improved to Score-A and 54.2% with a baseline Score-C improved to a Score-B (χ2 = 55,000, P < 0.001). Based on the number of VNCs, the improvement in malnutrition status following two sessions and three or more sessions was found to be 17.6% and 35.7%, respectively (P < 0.001). Our results confirm that VNC can improve the nutritional status of cancer patients. Hence, nutritional counseling should be an integral part of oncological treatment.

Assessing Frailty in Gastrointestinal Cancer: Two Diseases in One?

PURPOSEOF REVIEW

This review examines the challenges of treating gastrointestinal cancer in the aging population, focusing on the importance of frailty assessment. Emphasized are the rise in gastrointestinal cancer incidence in older adults, advances in frailty assessments for patients with gastrointestinal cancer, the development of novel frailty markers, and a summary of recent trials.

RECENT FINDINGS

Increasing evidence suggests that the use of a Comprehensive Geriatric Assessment (CGA) to identify frail older adults and individualize cancer care leads to lower toxicity and improved quality of life outcomes. However, the adoption of a full CGA prior to chemotherapy initiation in older cancer patients remains low. Recently, new frailty screening tools have emerged, including assessments designed to specifically predict chemotherapy-related adverse events. Additionally, frailty biomarkers have been developed, such as blood tests like IL-6 and performance tracking through physical activity monitors. The relevance of nutrition and muscle mass is discussed. Highlights from recent trials suggest the feasibility of successfully identifying patients most at risk of serious adverse events. There have been promising developments in identifying novel frailty markers and methods to screen for frailty in the older adult population. Further prospective trials that focus on and address the needs of the geriatric population for early identification of frailty in cancer care, facilitating a more tailored treatment approach. Practicing oncologists should select a frailty assessment to implement into their routine practice and adjust treatment accordingly.

High-protein home parenteral nutrition in malnourished oncology patients: a systematic literature review

INTRODUCTION

Up to 83% of oncology patients are affected by cancer-related malnutrition, depending on tumour location and patient age. Parenteral nutrition can be used to manage malnutrition, but there is no clear consensus as to the optimal protein dosage. The objective of this systematic literature review (SLR) was to identify studies on malnourished oncology patients receiving home parenteral nutrition (HPN) where protein or amino acid delivery was reported in g/kg bodyweight/day, and to compare outcomes between patients receiving low (< 1 g/kg bodyweight/day), standard (1-1.5 g/kg/day), and high-protein doses (> 1.5 g/kg/day).

METHODS

Literature searches were performed on 5th October 2021 in Embase, MEDLINE, and five Cochrane Library and Centre for Reviews and Dissemination databases. Searches were complemented by hand-searching of conference proceedings, a clinical trial registry, and bibliographic reference lists of included studies and relevant SLRs/meta-analyses.

RESULTS

Nineteen publications were included; sixteen investigated standard protein, two reported low protein, and one included both, but none assessed high-protein doses. Only one randomised controlled trial (RCT) was identified; all other studies were observational studies. The only study to compare two protein doses reported significantly greater weight gain in patients receiving 1.15 g/kg/day than those receiving 0.77 g/kg/day.

CONCLUSION

At present, there is insufficient evidence to determine the optimal protein dosage for malnourished oncology patients receiving HPN. Data from non-HPN studies and critically ill patients indicate that high-protein interventions are associated with increased overall survival and quality of life; further studies are needed to establish whether the same applies in malnourished oncology patients.

Interventions to improve quality of life in patients with head and neck cancers receiving radiation therapy: a scoping review

BACKGROUND

Quality of life (QOL) is impaired in patients with head and neck cancers (HNC) due to illness and treatment-associated morbidity. Although there is evidence from the studies on interventions' role in improving QOL receiving radiation therapy, these are not systematically synthesised. In this scoping review, we searched and synthesised the evidence on interventions to improve the QOL and its impact among patients with HNCs.

METHODS

This scoping review was conducted using the framework proposed by Arksey and O'Malley, and the extensions suggested by Levac et al. were incorporated. Two reviewers independently searched four electronic databases using key thesaurus and free-text terms, and the data was extracted, tabulated, synthesised and reported as categories.

RESULTS

Seventy-nine papers reported various interventions of diverse nature such as pharmacological, physical, nutritional, complementary and alternative therapies, psychosocial, oral care related, laser and photobiomodulation therapies, rehabilitative, educational, technology-based, surgical, device-related and nurse lead interventions. Most studies reported clinically meaningful impact of interventions on QOL, although the outcome differences were often statistically insignificant. Few studies reported a combination of interventions to address the multidimensional concerns faced by patients with HNCs. None of the studies examined the impact of interventions on QOL among long-term survivors of HNCs.

CONCLUSION

As QOL concerns in patients with HNCs are multifaceted, more extensive studies with complex multi-component interventions and robust research designs are warranted.

Dietary Intake Is Not Associated with Body Composition nor with Biochemical Tests but with Psychological Status of Cancer Patients Receiving Chemotherapy

Chemotherapy can negatively affect cancer patients' eating patterns, psychological status, body composition, and quality of life. In this study, we aimed to investigate the correlations between dietary intake/care and the psychological status of cancer patients treated with chemotherapy. An observational study was conducted on 75 participants during their first cycle of chemotherapy treatment, and they were followed up for three cycles. Each participant completed a reliable validated questionnaire, psychological questionnaire, quality of life questionnaire, and three-day food records. Dietary intake was considered adequate if there was an adherence of participants to dietary recommendations offered by the dietitian and was confirmed by ESHA analysis software (version 10.6.3). Seventy-five percent of participants had inadequate nutrition intake. All anthropometric measurements decreased after 2 months of chemotherapy regardless of patients' dietary intake. Approximately half of the participants reported depression and anxiety. There were significant differences between all nutrient intake levels when compared to the recommended dietary allowance except for fat, unsaturated fatty acids, and iron. Also, there were associations between nutritional intake and life quality and depression. In conclusion, poor dietary intake was associated with depression and insufficient macro- and micronutrient intake. Emotional and nutritional support from healthcare providers and family are highly necessary.

Nutritional Management of Oncological Symptoms: A Comprehensive Review

Throughout their experience of illness and during the course of treatment, a substantial proportion of cancer patients are prone to develop nutritional and/or metabolic disturbances. Additionally, cancer patients often encounter long-term side effects from therapies, which may lead to impaired digestion, nutrient absorption or bowel motility. Therefore, the preservation and maintenance of an optimal and balanced nutritional status are pivotal to achieving a better prognosis, increasing the tolerance and adherence to cancer therapies and improving the overall quality of life. In this context, personalized nutritional programs are essential for addressing conditions predisposing to weight loss, feeding difficulties, digestion problems and intestinal irregularity, with the goal of promoting adequate nutrient absorption and minimizing the detrimental effects of treatment regimens. The focus of this research is to examine the most common clinical conditions and metabolic changes that cancer patients may experience, including stomatitis, xerostomia, diarrhea, nausea, vomiting, dysphagia, sub-occlusion, dysgeusia, dysosmia, anorexia, and cachexia. Furthermore, we present a pragmatic example of a multidisciplinary workflow that incorporates customized recipes tailored to individual clinical scenarios, all while maintaining the hedonic value of the meals.

Optimizing clinical nutrition research: the role of adaptive and pragmatic trials

Evidence-based nutritional recommendations address the health impact of suboptimal nutritional status. Efficacy randomized controlled trials (RCTs) have traditionally been the preferred method for determining the effects of nutritional interventions on health outcomes. Nevertheless, obtaining a holistic understanding of intervention efficacy and effectiveness in real-world settings is stymied by inherent constraints of efficacy RCTs. These limitations are further compounded by the complexity of nutritional interventions and the intricacies of the clinical context. Herein, we explore the advantages and limitations of alternative study designs (e.g., adaptive and pragmatic trials), which can be incorporated into RCTs to optimize the efficacy or effectiveness of interventions in clinical nutrition research. Efficacy RCTs often lack external validity due to their fixed design and restrictive eligibility criteria, leading to efficacy-effectiveness and evidence-practice gaps. Adaptive trials improve the evaluation of nutritional intervention efficacy through planned study modifications, such as recalculating sample sizes or discontinuing a study arm. Pragmatic trials are embedded within clinical practice or conducted in settings that resemble standard of care, enabling a more comprehensive assessment of intervention effectiveness. Pragmatic trials often rely on patient-oriented primary outcomes, acquire outcome data from electronic health records, and employ broader eligibility criteria. Consequently, adaptive and pragmatic trials facilitate the prompt implementation of evidence-based nutritional recommendations into clinical practice. Recognizing the limitations of efficacy RCTs and the potential advantages of alternative trial designs is essential for bridging efficacy-effectiveness and evidence-practice gaps. Ultimately, this awareness will lead to a greater number of patients benefiting from evidence-based nutritional recommendations.

Patients Are Using Dietary Supplement for the Treatment of Their Diseases without Consultation with Their Physicians and Pharmacists

Inappropriate use of dietary supplements by patients might exacerbate their diseases. The aim of this study was to clarify the situation of dietary supplement use for disease treatment among patients. A cross-sectional online questionnaire survey was conducted between 18 and 30 November 2022. A preliminary survey revealed that the proportion of patients who used dietary supplements to treat their disease ranged from 7.7% (cancer) to 28.2% (menopausal disorder). In the actual survey, across all diseases, patients who used dietary supplements for treatment purposes were satisfied with their therapeutic effects. Information obtained via the internet was the most common reason given for starting to use supplements. The proportions of patients who used supplements concurrently with medicine ranged from 25.4% (liver disease) to 72.2% (mental disorder). Most users of supplements did not consult with their physicians or pharmacists about them. However, patients preferred face-to-face consultation with a physician or pharmacist when discussing the concomitant use of medicines. In conclusion, the role of pharmacists is important for the appropriate use of dietary supplements among patients, especially concomitant use with medicines. More awareness about dietary supplements is needed for healthcare professionals to consult with their patients.

Anti-Cancer Properties of Flaxseed Proteome

Flaxseed has been recognized as a valuable source of nutrients and bioactive compounds, including proteins that possess various health benefits. In recent years, studies have shown that flaxseed proteins, including albumins, globulins, glutelin, and prolamins, possess anti-cancer properties. These properties are attributed to their ability to inhibit cancer cell proliferation, induce apoptosis, and interfere with cancer cell signaling pathways, ultimately leading to the inhibition of metastasis. Moreover, flaxseed proteins have been reported to modulate cancer cell mechanobiology, leading to changes in cell behavior and reduced cancer cell migration and invasion. This review provides an overview of the anti-cancer properties of flaxseed proteins, with a focus on their potential use in cancer treatment. Additionally, it highlights the need for further research to fully establish the potential of flaxseed proteins in cancer therapy.

Impact of preoperative body composition in patients with renal cell carcinoma submitted to surgical treatment

Objective

To evaluate the impact of preoperative body composition in patients with renal cell carcinoma (RCC) undergoing surgical treatment.

Materials and Methods

This was a retrospective study of 52 patients with RCC undergoing total or partial nephrectomy. Body composition assessment was performed using the body mass index, together with computed tomography analysis at the level of the third lumbar vertebra to measure the area of visceral adipose tissue, as well as the area and density of skeletal muscle mass.

Results

Malnutrition, obesity and inadequate skeletal muscle gauge (SMG) were associated with higher hospital length of stay (p = 0.028, p = 0.02 and p = 0.012, respectively). Although the rates of postoperative symptoms and readmissions were low, survival was better among the patients with an adequate SMG than among those with an inadequate SMG (p = 0.003).

Conclusion

Among patients with RCC undergoing surgical treatment, preoperative body composition does not seem to be associated with the rates of perioperative complications, although an inadequate SMG seems to be associated with worse overall survival.

Effect of percutaneous endoscopic gastrostomy prior to oesophageal cancer surgery on postoperative wound complications in patients: A meta-analysis

It is still a matter of controversy whether percutaneous endoscopic gastrostomy(PEG) should be used prior to the operation for the purpose of feeding the patient with resectable oesophageal carcinoma (EC). Comparison was made between EC and preoperatively treated PEG and non-preoperative PEG. An extensive literature review has been conducted to determine the results about PEG and No-PEG trials. In this paper, we chose 4 papers out of 407 of them through a strict selection process. In this trial, there were 1027 surgical cases of oesophagus carcinoma, 152 with PEG pre-surgery and 875 without PEG. The total sample size ranged from 14 to 657. Two studies showed that there was no statistically significant difference in the occurrence of postoperative wound infection among PEG and No-PEG(OR, 1.03; 95% CI, 0.38, 2.80 p = 0.96), there was no statistical significance in the likelihood of anastomotic leak among PEG after surgery compared to No-PEG in 4 trials (OR, 1.13; 95% CI, 0.62-2.07 p = 0.69), and there were no statistical differences between PEG and No-PEG before operation on anastomotic stricture for esophagectomy(OR, 0.70; 95% CI, 0.31-1.56 p = 0.38). No wound or anastomosis complications were observed in the PEG group. Thus, PEG preoperatively is an effective and safe procedure without any harmful influence on gastrointestinal structure or anastomosing. It can be applied to patients with oesophagus carcinoma who have a high risk of undernutrition. Nevertheless, because of the limited number of randomized controlled trials in this meta-analysis, caution should be exercised in their treatment. More high-quality research involving a large sample is required to confirm the findings.

Integrated analysis of single-cell transcriptome and structural biology approach reveals the dynamics changes of NP subtypes and roles of Menaquinone in attenuating intervertebral disc degeneration

Intervertebral disc degeneration (IDD) is a progressive and chronic disease, the mechanisms have been studied extensively as a whole, while the cellular heterogeneity of cells in nucleus pulposus (NP) tissues remained controversial for a long time. This study conducted integrated analysis through single-cell sequencing analysis, weighted gene co-expression network analysis (WGCNA), and differential expression analysis, to systematically decipher the longitudinal alterations of distinct NP subtypes, and also analyzed the most essential genes in the development of IDD. Then, this study further conducted structural biology method to discover the potential lead compounds through a suite of advanced approaches like high-throughput screening (HTVS), pharmaceutical characteristics assessment, CDOCKER module as well as molecular dynamics simulation, etc., aiming to ameliorate the progression of IDD. Totally 5 NP subpopulations were identified with distinct biological functions based on their unique gene expression patterns. The predominant dynamics changes mainly involved RegNPs and EffNPs, the RegNPs were mainly aggregated in normal NP tissues and drastically decreased in degenerative NP, while EffNPs, as pathogenic subtype, exhibited opposite phenomenon. Importantly, this study further reported the essential roles of Menaquinone in alleviating degenerative NP cells for the first time, which could provide solid evidence for the application of nutritional therapy in the treatment of IDD. This study combined scRNA-seq, bulk-RNA seq and HTVS techniques to systematically decipher the longitudinal changes of NP subtypes during IDD. EffNPs were considered to be 'chief culprit' in IDD progression, while the novel natural drug Menaquinone could reverse this phenomenon.Communicated by Ramaswamy H. Sarma.

Prognostic value of controlling nutritional status on clinical and survival outcomes in cancer patients treated with immunotherapy

Cancer is a leading cause of death globally. Immunotherapy has shown promise in treating various types of cancer, but its effectiveness varies among patients. The Controlling Nutritional Status (CONUT) score has been linked to the prognosis of different cancers. However, its predictive value for immunotherapy outcomes is not well understood. Our research represents the pioneering meta-study to examine the prognostic value of the CONUT score on cancer patients treated with an immune checkpoint inhibitor (ICI). A comprehensive literature search was conducted using various databases including PubMed, the Cochrane Library, EMBASE, and Google Scholar. The study was conducted until July 28, 2023. This analysis encompassed a comprehensive evaluation of various clinical outcomes, namely overall survival (OS), progression-free survival (PFS), objective response rate (ORR), and disease control rate (DCR). 663 patients from 8 studies were included in this study. It showed that cancer patients with high CONUT score had poorer OS (HR: 1.94, 95% CI, 1.52-2.47, p < 0.001) and PFS (HR: 2.22, 95% CI, 1.48-3.31, p < 0.001), as well as worse ORR (OR: 0.46, 95% CI, 0.25-0.85, p = 0.013) and DCR (HR: 0.29, 95% CI, 0.14-0.59, p = 0.001). The CONUT score can predict the prognosis of tumor patients treated with ICIs.

Preoperative albumin-to-globulin ratio and prognostic nutritional index predict the prognosis of colorectal cancer: a retrospective study

The immunonutritional status has important effects on outcomes for cancer patients. Albumin-to-globulin ratio (AGR) and the prognostic nutrition index (PNI) are often used to assess the immunonutritional status of cancer patients. However, the clinical significance of these factors in colorectal cancer (CRC) remains unclear. We aimed to evaluate the clinical significance of the AGR and PNI in CRC. We reviewed the clinical data of 511 patients with CRC in two hospitals. Data from one institution was used as the training cohort. The optimal cutoff values for AGR and PNI in the training cohort were 1.4 and 48.65, respectively. Patients in both the low AGR and low PNI groups had poor overall survival (OS) and progression-free survival (PFS), while those in the low AGR-low PNI group had the lowest OS and PFS. Multivariate analysis revealed that preoperative AGR, preoperative PNI, gross type, and TNM stage were independent prognostic factors influencing OS in patients with CRC. Preoperative AGR, preoperative PNI, and TNM stage were independently associated with PFS in patients with CRC. According to the results of multivariate analysis in the training cohort, we developed the nomograms for OS and PFS and performed internal and external validation, which showed good prediction ability of the nomograms. In conclusion, preoperative AGR and PNI can be used as effective indicators to predict survival for patients with CRC. AGR and PNI may help develop effective adjuvant-therapy schedules.

May Nutritional Status Positively Affect Disease Progression and Prognosis in Patients with Esophageal and Pharyngeal Cancers? A Scoping Review of the Current Clinical Studies

BACKGROUND

Malnutrition in esophageal and pharyngeal cancer patients constitutes a common and serious concern, which significantly reduces patients' prognoses. Cancers of the esophagus and the pharynx can considerably impair feeding in patients, resulting in severe undernutrition. This is a scoping review that intends to critically analyze the most well-designed clinical studies investigating the potential beneficial impact of diverse nutritional assessment tools on the prognosis of patients with esophageal and pharyngeal cancers.

METHODS

The most accurate and remarkable scientific databases were comprehensively explored utilizing relative keywords to detect clinical studies that investigate whether nutritional status may affect disease prognosis.

RESULTS

Several assessment tools have evaluated and highlighted the potential beneficial impact of nutritional status on disease progression and patients' prognosis in both esophageal and pharyngeal cancers. Regarding esophageal cancer, CONUT, PNI, PG-SGA, and NRS-2002 are more commonly used, while albumin is also frequently evaluated. Regarding pharyngeal cancers, fewer studies are currently available. PNI has been evaluated, and its significance as a factor for shorter survival' times has been highlighted. The Comprehensive Nutritional Index has also been evaluated with positive results, as well as NRS 2002, GPS, and body-weight status. However, there is currently a lack of studies with an adequate number of women with cancer. An international literature gap was identified concerning follow-up studies with adequate methodology.

CONCLUSIONS

Nutritional status may significantly affect disease progression and patients' survival, highlighting the significance of a great nutritional status in individuals with esophageal and pharyngeal cancers. Further large-scale and well-designed prospective surveys should be performed to verify the potential beneficial effects of adequate nourishment in people suffering from cancer of the esophagus and pharynx.

Development and application of the Cancer Cachexia Staging Index for the diagnosis and staging of cancer cachexia

OBJECTIVE

The current tools for evaluating cancer cachexia are either too simple to reflect the far-reaching effects of cachexia or too complicated to be used in daily practice. This study aimed to develop a cancer cachexia staging index (CCSI) that is both practical and comprehensive.

METHODS

Patients with gastrointestinal cancers were prospectively included in the study. Clinical data including weight change, body composition, systematic inflammation, nutrition, and function status were entered into regression models to determine the best variable combination as well as their respective cutoff values and score distribution in the CCSI. The CCSI's ability to predict outcomes and evaluate the consequences of cachexia for patients were then assessed.

RESULTS

Clinical information and test results from 10 568 patients were used to develop a CCSI composed of subjective and objective measures. Subjective measures included body mass index-adjusted weight loss grade, rate of weight loss, inflammation (neutrophil-to-lymphocyte ratio and C-reactive protein level), and prealbumin level. Objective measures included appetite status and physical status. Patients were diagnosed and stratified by the total CCSI score into 3 subgroups: no cachexia, mild or moderate cachexia, and severe cachexia. The CCSI grades showed good survival discrimination and were independently predictive of survival in multivariate analysis. Compared with the traditional Fearon criteria for diagnosing cancer cachexia, the CCSI was more accurate in predicting postoperative complications (net reclassification index [NRI], 2.8%; 95% CI, 0.0104-0.0456%), death (NRI, 10.68%; 95% CI, 0.0429-0.1708%), recurrence (NRI, 3.71%; 95% CI, 0.0082-0.0685%), and overall survival (NRI, 8.5%; 95% CI, 0.0219-0.1533%). The CCSI also had better discriminative ability than Fearon criteria in discriminating nutritional status, body composition, and systematic inflammation in patients with or without cachexia. A more detailed evaluation of a randomly selected subgroup (n = 1566) showed that CCSI grades had good discrimination of appetite and food intake status, physical function and muscle strength, symptom burden, and quality of life.

CONCLUSIONS

The CCSI is a comprehensive and practical evaluation tool for cancer cachexia. It can predict postoperative outcomes and survival. The CCSI stages showed good discrimination when evaluating patients with cancer in terms of nutritional status, physical function, systematic inflammation, body composition, symptom burden, and quality of life.

The Level of Adherence to the ESPEN Guidelines for Energy and Protein Intake Prospectively Influences Weight Loss and Nutritional Status in Patients with Cancer

Nutrition therapy aims to prevent weight loss and its health consequences in patients with cancer. The aim of this study was to assess Greek patients' adherence to the ESPEN guidelines for oncology patients and its prospective effect on their body weight (BW) and nutritional status. In total, 152 patients with cancer were recruited from the Attikon University Hospital, Greece, and provided data in 2019 (baseline) and 2020 (follow-up) (drop-out rate = 28.3%). Nutritional status was assessed with the PG-SGA questionnaire. Patients were categorized based on whether they adhered at least to the minimum ESPEN-recommended intakes of energy (≥25 kcal/kg/day) or protein (≥1.0 g/kg/day) or not. On average, patients did not adhere to ESPEN guidelines for energy and protein intake. Most patients meeting the minimum recommendations had an improvement of their nutritional status at follow-up and increased their BW compared to those not meeting them. All patients with head, neck, and spinal cancer who met the minimum recommendations for energy intake improved their nutritional status at follow-up. This study showed that consuming at least the minimum amounts of protein and energy recommended by ESPEN may prevent from weight loss and improve nutritional status; however, the exact amounts need to be personalized.

Expert design thinking workshops to analyze users' perceived applicability of NUTRI-ONCOCARE algorithm to prevent and treat malnutrition in cancer patients under routine clinical practice conditions in Spain: the ALLIANCE study

PURPOSE

NUTRI-ONCOCARE algorithm has been developed to identify and treat patients with solid tumors who are at risk of malnutrition. The present study is aimed at analyzing users' opinion about this new tool and at assessing whether it is perceived as useful to achieve the behavioral change required for a successful integration of nutritional assessment into routine cancer care.

METHODS

Design thinking Double Diamond process was applied. A multidisciplinary team composed of ten potential end-users (four oncologists, three endocrinologists, one nutritionist, and two hospital pharmacists) participated in three different workshops aiming to analyze the different tasks included within the NUTRI-ONCOCARE algorithm.

RESULTS

Users agreed on the need to perform nutritional assessment around cancer diagnosis and through the course of the disease using standardized tools included in hospital nutritional protocols and involving healthcare professionals with nutrition expertise. Nutritional evaluation and intervention should be individual and comprehensive, considering not only nutritional parameters but also patients' functional status. According to participants' opinion, the implementation of nutritional screening in routine clinical practice is limited by the lack of time and staff to conduct nutritional assessments, the low level of nutrition expert participation, and the poor support provided by hospital managers, which are often unaware of nutrition's impact in cancer care.

CONCLUSIONS

Experts recognized the importance of considering nutritional status in cancer patients and identified the opportunity provided by the NUTRI-ONCOCARE algorithm for this purpose, as it meets main requirements for being used routinely in clinical practice.

The European Society for Blood and Marrow Transplantation (EBMT) roadmap and perspectives to improve nutritional care in patients undergoing hematopoietic stem cell transplantation on behalf of the Cellular Therapy and Immunobiology Working Party (CTIWP) and the Nurses Group (NG) of the EBMT

Malnutrition is the most common comorbidity during the continuum of hematopoietic stem cell transplant (HSCT) and negatively impacts clinical outcomes, response to therapy, quality of life, and costs. The intensive conditioning regimen administered before transplant causes inflammatory damages to the gastrointestinal system, which themselves contribute to trigger graft versus host disease (GvHD) in the allogeneic setting. GvHD and other post-transplant complications such as infections adversely affect food intake and gut absorption of nutrients. Consequently, patients exhibit signs of malnutrition such as weight loss and muscle wasting, thus triggering a "vicious circle" that favours additional complications. Among HSCT centres, there is marked variability in nutritional care, from screening for malnutrition to nutritional intervention. The present paper, elaborated by the Cellular Therapy and Immunobiology Working Party and the Nurses Group of the European Society for Blood and Marrow Transplantation, aims at defining a roadmap that identifies the main nutritional critical issues in the field of HSCT. This document will be propaedeutic to the development of clinical algorithms to counteract risk factors of malnutrition, based on scientific evidence and shared among HSCT centres, and thus maximize transplant outcomes.

Analysis of muscle mass by computed tomography in patients with head and neck cancer: a prospective study

Objective

To evaluate the preoperative muscle mass of patients with head and neck cancer (HNC) with computed tomography (CT), comparing the results obtained through analysis of cross-sectional areas at the level of the third lumbar vertebra (L3) with those obtained through analysis of cross-sectional areas at the levels of the third cervical and fourth thoracic vertebrae (C3 and T4, respectively).

Materials and Methods

A total of 63 patients with HNC were evaluated preoperatively. Using CT, we assessed muscle mass at L3, as well as at C3 and T4.

Results

Most (73.0%) of the patients had low muscle mass at L3, whereas 50.8% had a normal body mass index. The cross-sectional area at L3 correlated strongly with those at C3 and T4 (r = 0.831 and r = 0.763, respectively; p < 0.001 for both). In addition, the muscle mass index at L3 correlated strongly with those at C3 and T4 (r = 0.781 and r = 0.715, respectively; p < 0.001 for both).

Conclusion

Low muscle mass appears to be highly prevalent in patients with HNC. Measurements at C3 and T4 could represent alternative means of assessing muscle mass in such patients.

Real world prognostic utility of platelet lymphocyte ratio and nutritional status in first-line immunotherapy response in stage IV non-small cell lung cancer

BACKGROUND

Elevated platelet lymphocyte ratio (PLR) and low body mass index (BMI) are associated with inferior survival in non-small cell lung cancer (NSCLC) patients receiving immunotherapy (IO). We evaluated real-world prognostic utility of PLR, BMI, and albumin level in stage IV NSCLC patients receiving first line (1L) IO.

METHODS

We identified 75 stage IV patients who received 1L IO therapy at USC Norris Comprehensive Cancer Center and Los Angeles General Medical Center from 2015 to 2022. The primary outcome was overall survival (OS) from time of IO with attention to pre-treatment BMI < 22, albumin < 3.5 g/dL, and PLR > 180.

RESULTS

Median age was 66.5 years with 49 (65.3%) males. 25 (33.3%) had BMI < 22. 45/75 (60%) had PLR > 180. Patients with BMI < 22 had inferior OS (13.1 months (m) vs. 37.4 m in BMI > 28, p-value = 0.042) along with patients with albumin<3.5 g/dL (OS: 2.8 m vs. 14.6 m, p-value = 0.0027), and patients with PLR>180 (OS: 8.7 m vs. 23.0 m, p = 0.028). Composite BMI < 22, PLR > 180 had the worst OS, p-value = 0.0331. Multivariate analysis controlling for age, smoking, gender, PD-L1 tumor proportion score (TPS), and histology (adenocarcinoma, squamous, adenosquamous, and large cell) showed that BMI (HR: 0.8726, 95% CI: 0.7892-0.954) and PLR > 180 (HR: 2.48, 95% CI: 1.076-6.055) were significant in OS mortality risk.

CONCLUSION

Patients with a composite of BMI < 22, albumin < 3.5 g/dL, and PLR > 180 had significantly worse OS. This highlights the importance of screening for poor nutritional status and high PLR to better inform stage IV NSCLC patients receiving IO therapy of their prognosis and supportive care.

MICROABSTRACT

We evaluated real-world prognostic utility of platelet lymphocyte ratio (PLR), body mass index (BMI), and albumin level in 75 Stage IV NSCLC patients receiving first line IO. Patients with a composite of BMI < 22, albumin < 3.5 g/dL, and PLR > 180 had significantly worse OS. This highlights the importance of screening for poor nutritional status and high PLR to better inform stage IV NSCLC patients of their prognosis and to emphasize supportive care needs.

Common Variants in One-Carbon Metabolism Genes (MTHFR, MTR, MTHFD1) and Depression in Gynecologic Cancers

We investigated the association between methylenetetrahydrofolate reductase (gene MTHFR 677C>T, rs1801133), 5-methyltetrahydrofolate-homocysteine methyltransferase (MTR 2756A>G, rs1805087), and methylenetetrahydrofolate dehydrogenase, cyclohydrolase and formyltetrahydrofolate synthetase 1 (gene MTHFD1 1958G>A, rs2236225)-well-studied functional variants involved in one-carbon metabolism-and gynecologic cancer risk, and the interaction between these polymorphisms and depression. A total of 200 gynecologic cancer cases and 240 healthy controls were recruited to participate in this study. Three single-nucleotide variants (SNVs) (rs1801133, rs1805087, rs2236225) were genotyped using the PCR-restriction fragment length polymorphism method. Depression was assessed in all patients using the Hamilton Depression Scale. Depression was statistically significantly more frequent in women with gynecologic cancers (69.5% vs. 34.2% in controls, p < 0.001). MTHFD1 rs2236225 was associated with an increased risk of gynecologic cancers (in dominant OR = 1.53, p = 0.033, and in log-additive models OR = 1.37, p = 0.024). Moreover, an association was found between depression risk and MTHFR rs1801133 genotypes in the controls but not in women with gynecologic cancers (in codominant model CC vs. TT: OR = 3.39, 95%: 1.49-7.74, p = 0.011). Cancers of the female reproductive system are associated with the occurrence of depression, and ovarian cancer may be associated with the rs2236225 variant of the MTHFD1 gene. In addition, in healthy aging women in the Polish population, the rs1801133 variant of the MTHFR gene is associated with depression.

Nutrition support in pancreatic cancer: An expert statement on practical implementation of French guidelines

The European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines, shortened in 2021, are widely used for providing the most suitable nutrition support to patients with cancer. However, there is a lack of specialized guidelines for different cancer types. In 2020, members of the French medical and surgical societies involved in digestive oncology, nutrition and supportive care developed the Thésaurus National de Cancérologie Digestive (TNCD) practice guidelines which are specific nutritional and physical activity guidelines for patients with digestive cancers. These guidelines were recently updated in 2022. This review discusses the French intergroup guidelines, specifically in the context of pancreatic cancer at different stages of the disease. Pancreatic cancer is highly prevalent in Europe, with an increasing worldwide incidence over the last three decades. In France alone, about 14,000 new cases of pancreatic cancer are reported annually. More than 60% of patients with pancreatic cancer reportedly experience malnutrition and other nutritional issues which are known to have a negative impact on quality of life, treatment tolerability, general morbidity, and mortality. Given that the recommendations of TNCD guidelines correlate to other guidelines like the International Study Group on Pancreatic Surgery (ISGPS; for the perioperative setting), ESPEN and Spanish Society of Medical Oncology (SEOM) guidelines, their use can be suitably applied in other European countries. This review discusses the recommendations issued by nutrition guidelines, the challenges with effective integration of nutrition support in oncologic treatment, and the proposed algorithms on patient care pathways for pancreatic cancer management in the clinical setting.

The Prevalence and Impact of Nutritional Risk and Malnutrition in Gastrointestinal Surgical Oncology Patients: A Prospective, Observational, Multicenter, and Exploratory Study

A prospective, observational, multicenter, and exploratory study was conducted in 469 gastrointestinal cancer patients undergoing elective surgery. The Malnutrition Universal Screening Tool (MUST) and the Global Leadership Initiative on Malnutrition (GLIM) criteria were used to assess nutritional risk. On admission, 17.9% and 21.1% of patients were at moderate (MUST score 1) and severe (MUST score ≥ 2) nutritional risk, respectively. The GLIM criteria used in patients with a MUST score ≥ 2 showed moderate malnutrition in 35.3% of patients and severe in 64.6%. Forty-seven percent of patients with a MUST score ≥ 2 on admission had the same score at discharge, and 20.7% with a MUST score 0 had moderate/severe risk at discharge. Small bowel, esophageal, and gastric cancer and diabetes were predictors of malnutrition on admission. Complications were significantly higher among patients with a MUST score 1 or ≥2 either on admission (p = 0.001) or at discharge (p < 0.0001). In patients who received nutritional therapy (n = 231), 43% continued to have moderate/severe nutritional risk on discharge, and 54% of those with MUST ≥ 2 on admission maintained this score at discharge. In gastrointestinal cancer patients undergoing elective surgery, there is an urgent need for improving nutritional risk screening before and after surgery, as well as improving nutritional therapy during hospitalization.

A quality control circle process to improve enteral nutrition feeding support in discharged patients with colorectal cancer

Correct usage and maintenance of the enteral nutrition feeding pump system is always a challenge in nutrition support for patients with colorectal cancer (CRC). However, there are few studies on the sustained accuracy improvement of the enteral nutrition feeding system in discharged CRC patients. Here, we established a seven-month quality control circle (QCC) activity with the theme of improving the performance of home enteral feeding pumps (EFP) and examined the effect of QCC activity on the nutritional state and quality of life in discharged CRC patients. We enrolled 100 discharged CRC patients treated with home enteral nutrition from Zhejiang Cancer Hospital between March 2020 and December 2021. The patients were randomly split into two research groups: one participated in the QCC activity (n = 50) and the other did not (n = 50). QCC analysis indicated that the top 3 causes of EFP inaccurate usage are the simple and boring contents of training, various types of pumps, no examination rules, and lack of management. Furthermore, both intra- and inter-group comparisons showed that QCC significantly improved the patients' pass rate of nutrition pump operation from 52 to 70% after 1-month of activity, which gradually improved and got the highest (90%) after 3 months (p < 0.05). Interestingly, the established QCC activity significantly increased the patient-generated subjective global assessment (PG-SGA) and Barthel index (BI) scores, body fat mass (BFM) and superior longitudinal muscle (SLM) by intra- and inter-group comparisons. In this study, we clarified the main causes of inaccurate EFP usage and established a QCC process to improve the pass rate of EFP usage. It finally leads to the improvement of nutritional state and quality of life in CRC patients.

The efficacy of fat-free mass index and appendicular skeletal muscle mass index in cancer malnutrition: a propensity score match analysis

Background

Reduced muscle mass (RMM) is a phenotypic criterion for malnutrition; the appendicular skeletal muscle mass index (ASMI) and fat-free mass index (FFMI) are both applicable indicators in the global leadership initiative on malnutrition (GLIM) guideline. However, their sensitivity and prognostic effect remain unclear.

Methods

Clinical data of 2,477 patients with malignant tumors were collected. Multi-frequency bioelectrical impedance analysis was used to obtain ASMI and FFMI. RMM was confirmed by ASMI (< 7.0 kg/m² for men and < 5.7 kg/m² for women) or FFMI (< 17 kg/m² for men and < 15 kg/m² for women). Propensity score match analysis and logistic regression analysis were used to evaluate the efficacy of FFMI and ASMI in diagnosing severe malnutrition and multivariate Cox regression analysis to determine the efficacy of RMM in predicting survival.

Results

In total, 546 (22.0%) and 659 (26.6%) participants were diagnosed with RMM by ASMI (RMM.ASMI group) and FFMI (RMM.FFMI group); 375 cases overlapped. Body mass index (BMI), midarm circumference, triceps skinfold thickness, and maximum calf circumference were all significantly larger in the RMM.FFMI group for both sexes (P < 0.05). A 1:1 matched dataset constructed by propensity score match contained 810 cases. RMM.FFMI was an influential factor of severe malnutrition with HR = 3.033 (95% CI 2.068-4.449, P < 0.001), and RMM.ASMI was a predictive factor of overall survival (HR = 1.318, 95% CI 1.060-1.639, P = 0.013 in the RMM.ASMI subgroup, HR = 1.315, 95% CI 1.077-1.607, P = 0.007 in the RMM.FFMI subgroup).

Conclusion

In general, RMM indicates negative clinical outcomes; when defined by FFMI, it predicts nutritional status, and when defined by ASMI, it is related to poor survival in cancer patients.

Standard Hypercaloric, Hyperproteic vs. Leucine-Enriched Oral Supplements in Patients with Cancer-Induced Sarcopenia, a Randomized Clinical Trial

(1) Background: Malnutrition frequently affects patients with cancer, and it negatively impacts treatment tolerance, clinical outcomes and survival. Thus, appropriate nutritional screening and early nutrition support are extremely recommended. Currently, a significant number of oral supplements (OS) are commercially available; despite this, there is a lack of evidence for recommending specific OS, including leucine-enriched OS, for nutritional support in patients with cancer. (2) Aim: To compare the clinical evolution of patients with cancer (undergoing systemic treatment) that received standard hypercaloric, whey protein-based hyperproteic oral supplements vs. hypercaloric, hyperproteic leucine-enriched OS using a novel morphofunctional nutritional evaluation. (3) Patients and methods: This paper details an open-label, controlled clinical study in which patients were randomly assigned to receive nutritional treatment with whey protein-based hyperproteic oral supplements (control group) vs. hypercaloric, hyperproteic leucine-enriched OS (intervention group) during a twelve-week period. Forty-six patients were included; epidemiological, clinical, anthropometric, ultrasound (muscle echography of the rectus femoris muscle of the quadriceps and abdominal adipose tissue) and biochemical evaluation were performed. All patients received additional supplementation with vitamin D. (4) Results: Nutritional parameters (including bioimpedance, anthropometric, ultrasound and biochemical variables) of all included patients remained stable after the nutritional intervention. Extracellular mass tended to increase in the patients that received the leucine-enriched formula. Functionality (evaluated through the stand-up test) improved in both groups (p < 0.001). Prealbumin, transferrin levels and superficial adipose tissue increased in the control group (p < 0.05), while self-reported quality of life improved in all the evaluated patients (p < 0.001). (5) Conclusions: Nutritional support with hypercaloric, hyperproteic (with whey protein) OS and vitamin D supplementation were associated with the maintenance of body composition and improvements in functionality and in quality of life in the patients with cancer undergoing systemic treatment. No significant benefits were observed when a leucine-enriched formula was used.

Predictors of Central Vascular Access Device Bloodstream Infections in Patients With Acute Leukemia and Neutropenia: A Retrospective Case-Control Chart Review

Central vascular access devices (CVADs) are standard for the treatment of leukemia. The objectives of this study were to examine predictors for central line-associated bloodstream infection (CLABSI) and causative microorganisms. A retrospective case/control design was used to examine electronic health records (EHRs) of patients with acute leukemia, a CVAD, and neutropenia. Variables were examined for differences between those who developed bacteremia (cases: n = 10) and those who did not (controls: n = 13). Variables included conditions of health (eg, patient history, laboratory results at the time of nadir, nutritional intake during hospitalization, and CVAD care practices). Fisher exact and Mann-Whitney U tests were used for comparison. Nine organisms were identified, including viridans group streptococci (20%) and Escherichia coli (20%). No statistical differences in variables were found between groups. However, over 50% of the nutritional intake data was missing due to lack of documentation. These findings indicate that further study is needed to examine barriers for electronic documentation. The data collection site found opportunities to improve patient care that included education regarding the daily care of CVADs, collaboration with nutritional services to ensure accurate assessments, and coordination with clinical information systems to improve clinical documentation compliance.

The Diet as a Modulator of Tumor Microenvironment in Colorectal Cancer Patients

Colorectal cancer (CRC) is one of the most common cancers in Western countries and remains the second most common cause of cancer death worldwide. Many studies show the importance of diet and lifestyle in the incidence of CRC, as well as in CRC prevention. However, this review summarizes those studies that analyze the impact of nutrition on tumor microenvironment modulation and cancer progression. We review the available information about the effects of specific nutrients on cancer cell progression and on the different cells within the tumor microenvironment. Diet and nutritional status in the clinical management of colorectal cancer patients are also analyzed. Finally, future perspectives and challenges are discussed, with a view to improving CRC treatments by employing nutritional approaches. These promise great benefits and will eventually improve CRC patients' survival.

Clinical impacts of the concomitant use of L-asparaginase and total parenteral nutrition containing L-aspartic acid in patients with acute lymphoblastic leukemia

Introduction

L-asparaginase (ASNase) depletes L-asparagine and causes the death of leukemic cells, making it a mainstay for the treatment of acute lymphoblastic leukemia (ALL). However, ASNase's activity can be inhibited by L-aspartic acid (Asp), which competes for the same substrate and reduces the drug's efficacy. While many commercially used total parenteral nutrition (TPN) products contain Asp, it is unclear how the concomitant use of TPNs containing Asp (Asp-TPN) affects ALL patients treated with ASNase. This propensity-matched retrospective cohort study evaluated the clinical effects of the interaction between ASNase and Asp-TPN.

Methods

The study population included newly diagnosed adult Korean ALL patients who received VPDL induction therapy consisting of vincristine, prednisolone, daunorubicin, and Escherichia coli L-asparaginase between 2004 and 2021. Patients were divided into two groups based on their exposure to Asp-TPN: (1) Asp-TPN group and (2) control group. Data, including baseline characteristics, disease information, medication information, and laboratory data, were collected retrospectively. The primary outcomes for the effectiveness were overall and complete response rates. Relapse-free survival at six months and one year of treatment were also evaluated. The safety of both TPN and ASNase was evaluated by comparing liver function test levels between groups. A 1:1 propensity score matching analysis was conducted to minimize potential selection bias.

Results

The analysis included a total of 112 ALL patients, and 34 of whom received Asp-TPN and ASNase concomitantly. After propensity score matching, 30 patients remained in each group. The concomitant use of Asp-TPN and ASNase did not affect the overall response rate (odds ratio [OR] 0.53; 95% confidence interval [CI] = 0.17–1.62) or the complete response rate (OR 0.86; 95% CI = 0.29–2.59) of the ASNase-including induction therapy. The concomitant use of Asp-TPN and ASNase also did not impact relapse-free survival (RFS) at six months and one year of treatment (OR 1.00; 95% CI = 0.36–2.78 and OR 1.24; 95% CI, 0.50–3.12, respectively). The peak levels of each liver function test (LFT) and the frequency of LFT elevations were evaluated during induction therapy and showed no difference between the two groups.

Conclusion

There is no clear rationale for avoiding Asp-TPN in ASNase-treated patients.

Cancer-associated cachexia - understanding the tumour macroenvironment and microenvironment to improve management

Cachexia is a devastating, multifactorial and often irreversible systemic syndrome characterized by substantial weight loss (mainly of skeletal muscle and adipose tissue) that occurs in around 50-80% of patients with cancer. Although this condition mainly affects skeletal muscle (which accounts for approximately 40% of total body weight), cachexia is a multi-organ syndrome that also involves white and brown adipose tissue, and organs including the bones, brain, liver, gut and heart. Notably, cachexia accounts for up to 20% of cancer-related deaths. Cancer-associated cachexia is invariably associated with systemic inflammation, anorexia and increased energy expenditure. Understanding these mechanisms is essential, and the progress achieved in this area over the past decade could help to develop new therapeutic approaches. In this Review, we examine the currently available evidence on the roles of both the tumour macroenvironment and microenvironment in cancer-associated cachexia, and provide an overview of the novel therapeutic strategies developed to manage this syndrome.

Association between Posttreatment Serum Platelet-to-Lymphocyte Ratio and Distant Metastases in Patients with Hepatocellular Carcinoma Receiving Curative Radiation Therapy

Background: We sought to investigate whether serum immune and inflammatory parameters can help to predict distant metastasis (DM) in patients with unresectable hepatocellular carcinoma (HCC) undergoing curative radiation therapy (RT). Methods: A total of 76 RT courses were analyzed. The following variables were included in the analysis: systemic inflammation index, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio (PLR), prognostic nutritional index (PNI), absolute lymphocyte count, lymphocyte-to-monocyte ratio, albumin, albumin-to-alkaline phosphatase ratio, RT-related parameters, and levels of total protein, hemoglobin, α-fetoprotein, and PIVKA-II. Distant control (DC) and overall survival (OS) rates were calculated and compared. Results: The mean age was 61.4 years, and most patients were men (n = 62, 81.6%). The median RT fraction number and fractional doses were 12 (range, 4–30) and 5 (range, 2–12) Gy, respectively. With a median follow-up of 12 (range, 3.1–56.7) months, the 1-year DC and OS rates were 64.4% and 55.2%, respectively. The development of DM significantly deteriorated OS (p = 0.013). In the multivariate analysis, significant independent prognostic indicators for DC and OS rates were the highest posttreatment PLR (≤235.7 vs. >235.7, p = 0.006) and the lowest posttreatment PNI (≤25.4 vs. >25.4, p < 0.001), respectively. Conclusions: Posttreatment serum PLR might be helpfully used as a predictive biomarker of DM in unresectable HCC patients undergoing RT. Future research is necessary to confirm our findings.

Impact of Dietary Counseling on Health-Related Quality of Life in Patients with Cancer Awaiting Hepato-Pancreato-Biliary Surgery

We examined the effectiveness of dietary counseling performed within a trimodal prehabilitation study for patients with cancer awaiting hepato-pancreato-biliary (HPB) surgery. Additionally, we explored relationships between nutritional status and health-related quality of life (HRQoL). The dietary intervention aimed to achieve a protein intake of 1.5 g/kg/day and reduce nutrition-impact symptoms. Patients received dietary counseling 4 weeks prior to surgery (prehabilitation group); the rehabilitation group just before surgery. We used 3-day food journals to calculate protein intake and the abridged Patient-generated Subjective Global Assessment questionnaire (aPG-SGA) to determine nutritional status. We utilized the Functional Assessment of Cancer Therapy-General questionnaire to measure HRQoL. Sixty-one patients participated in the study (30 = prehabilitation). Dietary counseling achieved a significant increase in preoperative protein intake (+0.3 ± 0.1 g/kg/day, P = 0.007), with no change in the rehabilitation group. Dietary counseling did not mitigate a significant increase in aPG-SGA postoperatively (prehabilitation: +5.8 ± 1.0; rehabilitation: +3.3 ± 1.0; P < 0.05). aPG-SGA was predictive of HRQoL (β = -1.77, P < 0.0001). HRQoL remained unchanged in both groups over the study period. Dietary counseling within a HPB prehabilitation program improves preoperative protein intake, but not aPG-SGA, which is predictive of HRQoL. Future studies should examine whether specialized medical management of nutrition-impact symptoms would improve HRQoL outcomes within a prehabilitation model.

Nutritional Intake, Hospital Readmissions and Length of Stay in Hospitalised Oncology Patients

BACKGROUND

Poor food intake is an independent risk factor for malnutrition in oncology patients, and achieving adequate nutrition is essential for optimal clinical and health outcomes. This study investigated interrelationships between nutritional intake and clinical outcomes in hospitalised adult oncology patients.

METHODS

Estimated nutrition intake data were obtained from patients admitted to a 117-bed tertiary cancer centre during May-July 2022. Clinical healthcare data, including length of stay (LOS) and 30-day hospital readmissions, were obtained from patient medical records. Statistical analysis, including multivariable regression analysis, assessed whether poor nutritional intake was predictive of LOS and readmissions.

RESULTS

No relationships between nutritional intake and clinical outcomes were evident. Patients at risk of malnutrition had lower mean daily energy (-898.9 kJ, p = 0.001) and protein (-10.34 g, p = 0.015) intakes. Increased malnutrition risk at admission prolonged LOS (1.33 days, p = 0.008). Hospital readmission rates were 20.2%, and associated with age (r = -0.133, p = 0.015), presence of metastases (r = 0.125, p = 0.02) and longer LOS (1.34 days, r = 0.145, p = 0.02). Sarcoma (43.5%), gynaecological (36.8%) and lung (40.0%) cancers had the highest readmission rates.

CONCLUSIONS

Despite research showing the benefits of nutritional intake during hospitalisation, evidence continues to emerge on the relationship between nutritional intake and LOS and readmissions that may be confounded by malnutrition risk and cancer diagnosis.