Phase Angle, a Cornerstone of Outcome in Head and Neck Cancer

Prognostic value of bioelectrical impedance analysis in head and neck cancer patients undergoing radiotherapy: a VALOR® study

Introduction

Bioelectrical impedance analysis (BIA) serves as a method to estimate body composition. Parameters such as phase angle (PA), standardized phase angle (SPA), body mass cell (BCM), BCM index (BCMI), and fat-free mass (FFM) might significantly impact the prognosis of head and neck cancer (HNC) patients. The present study aimed to investigate whether bioelectrical parameters can be used to predict survival in the HNC population and establish the optimal cutoff points for predictive accuracy.

Methods

A multicenter observational study was performed across 12 tertiary hospitals in Andalusia (a region from the south of Spain). A total of 494 patients diagnosed with HNC between 2020 and 2022 at different stages were included in this study, with a minimum follow-up period of 12 months. The BIA assessment was carried out during the first 2 weeks of radical radiotherapy treatment with chemotherapy or other systemic treatments. A multivariate logistic regression analysis of overall survival, complications, hospital admission, and palliative care and its relationship with BIA nutritional assessment was performed.

Results

Significant prognostic factors identified in the multivariable analysis encompassed phase angle (PA), standardized phase angle (SPA), body cell mass (BCM), and BCM index (BCMI). Lower PA and BCM values were significantly associated with adverse clinical outcomes. A BCM threshold above 17 kg/m2 was the most significant predictor for predicting survival within the overall HNC population. The PA values of <5.1° in male and <4.8° in female patients showed the best predictive potential for mortality. Increased PA (as a continuous variable) demonstrated a significantly reduced risk for mortality (OR, 0.64; 95% CI, 0.43-0.94; p < 0.05) and a decreased likelihood of hospital admission (OR, 0.75; 95% CI, 0.52-1.07; p < 0.05). Higher BCM correlated with a lower risk of mortality (OR, 0.88; 95% CI, 0.80-0.96; p < 0.01) and a diminished probability of hospital admission (OR, 0.91; 95% CI, 0.83-0.99; p < 0.05).

Conclusion

BIA is a crucial tool in the nutritional assessment of HNC patients. BCM and PA are the main bioelectrical parameters used to predict clinical outcomes in this population. Future studies are needed to validate BIA variables in a large cohort to ensure whether early intensification of nutritional treatment would improve survival.

Irradiation dose to the swallowing apparatus impacts nutritional status in head and neck cancer patients-results from the prospective randomized HEADNUT trial

PURPOSE

To investigate the influence of radiation dose to the swallowing muscles on the nutritional status in patients with head and neck cancer undergoing primary or adjuvant (chemo)radiotherapy (C)RT.

METHODS

Between 2018 and 2020, 61 patients were prospectively randomized into the so-called HEADNUT trial (head and neck cancer patients undergoing nutritional intervention). Follow-up was continued until 2022. Contouring of the swallowing apparatus included the superior (scm), middle (mcm), and inferior constrictor muscle (icm), the cricopharyngeal muscle (cphm), and the esophageal inlet. Nutritional status was assessed by bioelectrical impedance analysis (BIA) at the beginning and the end of radiotherapy. The posttherapeutic nutritional status was evaluated by the BIA-derived fat-free mass index (FFMI; kg/m2). Malnutrition was assumed at FFMI values of < 15 (women) and < 17 (men) kg/m2. To find differences between dosimetric parameters in well- and malnourished patients, Mann-Whitney U test was used. To model the association between malnutrition and its potentially influencing variables, several logistic regression models were built.

RESULTS

The following parameters differed between well- and malnourished patients at the end of therapy: icm Dmean, V40Gy (%), V50Gy (%), and V60Gy (%), and sphm V40Gy (%). After entering these parameters into a multivariable logistic regression model (dosimetric model), icm Dmean (b = -0.12; Exp(b) = 0.88; 95% CI: 0.78-1.0; p = 0.06) and icm V40Gy (%; b = 0.06; Exp(b) = 1.07; 95% CI: 1-1.13; p = 0.04) proved to be independent dosimetric predictors of malnutrition. We only determined the cut-off value for predicting malnutrition for icm V40Gy (%) since it was the only parameter which met p < 0.05. The optimal cut-off value for the predictor V40Gy (%) based on the Youden Index was 85.6%. Another logistic regression model (dosimetric-clinical model) consisted of icm V40 (%) and the clinical parameters tumor localization, malnutrition before RT, gender, and combined chemotherapy. It was confirmed that both icm V40% (b = -1.9; Exp(b) = -2.7; 95% CI: 0.01-0.8; p = 0.03) and malnutrition at baseline (b = -1.9; Exp(b) = 4.4; 95% CI: 8.4-816.6; p = 0.0002) were independent predictors of subsequent malnutrition the end of RT.

CONCLUSION

Establishment of a normal nutritional status before the start of RT and adherence to dose constraints for the swallowing apparatus may prevent malnutrition in head and neck cancer patients at the end of therapy. Specifically, we suggest an icm V40Gy (%) of more than 86% to be predictive for nutritional complications.

An analysis of phase angle and standard phase angle cut-off values and their association with survival in head and neck cancer patients undergoing radiotherapy

OBJECTIVE

The objective of this study is to identify the cutoff values for phase angle (PA) and standard phase angle (SPA) parameters, as determined by bioelectrical impedance analysis (BIA), for predicting malnutrition and investigating their association with overall survival in head and neck cancer (HNC) patients undergoing radiotherapy.

METHODS

In this study, nutritional assessment and follow-up of HNC patients undergoing radiotherapy (RT) between November 2017 and September 2022 were assessed. Nutritional assessment, body composition (BC), and PA results obtained from BIA (Tanita MC-980) were retrospectively evaluated. Statistical Package for Social Sciences (SPSS) version 25.0 (IBM Corp., Armonk, NY, USA) was used for statistical analysis. The results were evaluated at a confidence interval of 95% and a significance level of p ≤ 0.05.

RESULTS

A total of 53 patients, including 37 (70%) men and 16 (30%) women, with a median age of 60 (23-87 years) were included. The median follow-up time was 51 (range 24-59) months. The mean PA of the patients was calculated as 4.99° (±0.92, 95% CI: 4.74-5.25). The PA of patients with malnutrition (4.66° ± 0.87) was lower than that of well-nourished patients (5.71° ± 0.56) (p < 0.001). As a result of the ROC analysis based on this finding, the ideal PA cut-off point for determining the presence of malnutrition was found to be 5.65, with a sensitivity of 85%, specificity of 79%, accuracy of 83%, and a model discrimination power of excellent level (AUC: 85%, p < 0.001). The median overall survival time of the patients was calculated as 51 months (24-59 months). The mortality rate during the follow-up period was 13%, while the 1-, 3-, and 5-year overall survival rates of the patients were 96.1%, 89.3%, and 86.8%, respectively. Patients with SPA values less than -1.65 had a 5-year overall survival rate of 77.4%, while those with SPA values greater than or equal to -1.65 had a 5-year overall survival rate of 100% (p = 0.030) CONCLUSION: Our study recommends using PA and SPA as standard criteria for detecting malnutrition in HNC patients undergoing RT, with cut-off points of 5.65 and -1.65 respectively, to prevent treatment interruptions and improve outcomes. Further research is needed to validate the SPA cut-off value and its relationship with clinical outcomes, as SPA may be a more effective predictor of malnutrition and overall survival than PA alone.

Phase Angle in Head and Neck Cancer: A Sex-Differential Analysis from Biological and Clinical Behavior to Health-Related Quality of Life

Head and neck cancer (H&NC) is a diverse category of tumors related to malignancies in the common aerodigestive pathway, with high metabolic rate, poor nutritional and treatment outcomes, and elevated mortality despite the best standard treatment. Herein, we focus on determining how the phase angle (PA) differs across sex as a predictor of poor prognosis, low quality-of-life (QoL) scores, and mortality in patients with head and neck cancer. This follow-up study presents a sex-differential analysis in a prospective cohort of 139 head and neck cancer patients categorized by sex as male (n = 107) and female (n = 32). Patients were compared in terms of nutritional, biochemical, and quality-of-life indicators between low and normal PA in women (<3.9° (n = 14, 43.75%) and ≥3.9°) and men (<4.5° (n = 62, 57.9%) and ≥4.5°). Our results show that most patients were in locally advanced clinical stages (women: n = 21 (65.7%); men: n = 67 (62.6%)) and that patients with low PA had a lower punctuation in parameters such as handgrip strength, four-meter walking speed, albumin, C-reactive protein (CRP), and CRP/albumin ratio (CAR), as well as the worst QoL scores in functional and symptomatic scales in both the male and female groups. A comparison between sexes revealed significant disparities; malnourishment and tumor cachexia related to an inflammatory state was more evident in the women's group.

The role of bioelectrical phase angle in patients with heart failure

The most challenging feature of heart failure (HF) still remains the evaluation of congestion. Residual congestion at discharge and the difficulties in perfectly dosing therapies in order to balance the hydration status of the patient are the most worrisome issues when dealing with HF.The use of bioimpedance vector analysis (BIVA) might promote a different approach in the general management of patients with HF. BIVA is a reliable, fast, bedside tool able to assess the congestion status. It proved to be helpful to physicians for diagnosing congestive status, managing therapies, and providing prognostic information in the setting of HF.Bioelectrical Phase Angle (PhA) - as derived from equations related to the parameters of BIVA - recently surged as a possible biomarker for patients with HF. Studies provided data about the application of PhA in the clinical management and in the overall risk stratification of HF patients.Basically, the use of PhA might be considered as a holistic evaluation of patients with HF which includes the need for a multiparametric approach able to effectively depict the clinical status of patients. There is no definite biomarker able to comprehensively describe and identify all the features of HF patient, but scores based on molecules/techniques able to explore the different pathogenetic mechanisms of HF are desirable.The aim of this review was to provide a comprehensive evaluation of literature related to PhA role in HF and the impact of this biomarker on clinical management and risk stratification of HF patients.

Phase Angle and Nutritional Status: The Impact on Survival and Health-Related Quality of Life in Locally Advanced Uterine Cervical Cancer

The phase angle, an indicator of muscle mass status and membrane cell integrity, has been associated with low survival, poorer clinical outcomes, and worse quality of life among cancer patients, but information on women with uterine cervical cancer (UCCa) is scarce. In this prospective study, we used a bioelectrical impedance analyzer to obtain the PA of 65 women with UCCa. We compared the health-related quality of life and inflammatory and nutritional indicators between low PA and normal PA. The mean age was 52 ± 13. The low PA and normal PA groups differed in terms of the C-reactive protein (15.8 ± 19.6 versus 6.82 ± 5.02, p = 0.022), glucose (125.39 ± 88.19 versus 88.78 ± 23.08, p = 0.021), albumin (3.9 ± 0.39 versus 4.37 ± 0.30, p = 0.000), EORTC QLQ-C30 loss of appetite symptom scale score (33.33 (0.0-100.00) versus 0.0 (0.0-0.0), p = 0.005), and EORTC QLQ-CX24 menopausal symptoms scale score (0.0 (0.0-33.33) versus 0.0 (0.0-100.0), p = 0.03). The main finding of the present study is the interaction between PA and obesity as critical cofactors in the UCCa adeno and adenosquamous histologic variants, to a greater extent than cervical squamous cell carcinoma.

The Role of Standardized Phase Angle in the Assessment of Nutritional Status and Clinical Outcomes in Cancer Patients: A Systematic Review of the Literature

Compared with the phase angle (PA), the predictive ability of the standardized phase angle (SPA) in assessing nutritional status and clinical outcomes in cancer patients remains uncertain. This review aimed to assess (1) the relationship between SPA and nutritional status and clinical outcomes (including complications and survival) in cancer patients; (2) the predictive ability of SPA alone and in comparison with the predictive ability of PA; and (3) the cut-off value of SPA in cancer patients. Studies that addressed the relationship of SPA use to nutritional status, complications, and survival in cancer patients were searched and identified from six electronic databases (PubMed, Medline, CINAHL, Embase, Web of Science, and the Cochrane Library). The included studies were considered to meet the following criteria: English studies with original data that reflected the effects of SPA on nutritional status and clinical outcomes (including complications and survival) and reported a cut-off value of SPA in cancer patients aged ≥18. Thirteen studies that included a total of 2787 participants were evaluated. Five studies assessed the relationship between SPA and nutritional status, and four of them reported a positive relationship between SPA and nutritional status in cancer patients, even considering SPA as a predictor. Twelve studies assessed the relationship between SPA and clinical outcomes in cancer patients. Two-thirds of the studies that evaluated complications reported the predictive ability of SPA; 30% of survival studies reported a positive relationship, 40% reported SPA as a predictor, and 30% reported no relationship. The standard cut-off value for SPA has not yet been determined. Data from the selected studies suggest that SPA might be a predictor of nutritional status. Further studies are needed to determine the value of SPA in predicting nutritional status and clinical outcomes in cancer patients.

Phase angle derived from bioelectrical impedance analysis as a marker for predicting sarcopenia

Sarcopenia is commonly defined as the age-related loss of muscle mass and function and may be caused by several factors, such as genetics, environmental conditions, lifestyle, drug use, and, in particular, comorbidities. People with pre-existing conditions are more likely to develop sarcopenia and subsequently have a less favorable prognosis. Recently, phase angle (PhA), which is derived from bioelectrical impedance analysis (BIA), has received a great deal of attention, and numerous studies have been carried out to examine the relationship between PhA and sarcopenia in different conditions. Based on these studies, we expect that PhA could be used as a potential marker for sarcopenia in the future.