Chemotherapy-Related Toxicity, Nutritional Status and Quality of Life in Precachectic Oncologic Patients with, or without, High Protein Nutritional Support. A Prospective, Randomized Study

Biomarker endpoints in cancer cachexia clinical trials: Systematic Review 5 of the cachexia endpoint series

Regulatory agencies require evidence that endpoints correlate with clinical benefit before they can be used to approve drugs. Biomarkers are often considered surrogate endpoints. In cancer cachexia trials, the measurement of biomarkers features frequently. The aim of this systematic review was to assess the frequency and diversity of biomarker endpoints in cancer cachexia trials. A comprehensive electronic literature search of MEDLINE, Embase and Cochrane (1990-2023) was completed. Eligible trials met the following criteria: adults (≥18 years), prospective design, more than 40 participants, use of a cachexia intervention for more than 14 days and use of a biomarker(s) as an endpoint. Biomarkers were defined as any objective measure that was assayed from a body fluid, including scoring systems based on these assays. Routine haematology and biochemistry to monitor intervention toxicity were not considered. Data extraction was performed using Covidence, and reporting followed PRISMA guidance (PROSPERO: CRD42022276710). A total of 5975 studies were assessed, of which 52 trials (total participants = 6522) included biomarkers as endpoints. Most studies (n = 29, 55.7%) included a variety of cancer types. Pharmacological interventions (n = 27, 51.9%) were most evaluated, followed by nutritional interventions (n = 20, 38.4%). Ninety-nine different biomarkers were used across the trials, and of these, 96 were assayed from blood. Albumin (n = 29, 55.8%) was assessed most often, followed by C-reactive protein (n = 22, 42.3%), interleukin-6 (n = 16, 30.8%) and tumour necrosis factor-α (n = 14, 26.9%), the latter being the only biomarker that was used to guide sample size calculations. Biomarkers were explicitly listed as a primary outcome in six trials. In total, 12 biomarkers (12.1% of 99) were used in six trials or more. Insulin-like growth factor binding protein 3 (IGFBP-3) and insulin-like growth factor 1 (IGF-1) levels both increased significantly in all three trials in which they were both used. This corresponded with a primary outcome, lean body mass, and was related to the pharmacological mechanism. Biomarkers were predominately used as exploratory rather than primary endpoints. The most commonly used biomarker, albumin, was limited by its lack of responsiveness to nutritional intervention. For a biomarker to be responsive to change, it must be related to the mechanism of action of the intervention and/or the underlying cachexia process that is modified by the intervention, as seen with IGFBP-3, IGF-1 and anamorelin. To reach regulatory approval as an endpoint, the relationship between the biomarker and clinical benefit must be clarified.

Body weight and composition endpoints in cancer cachexia clinical trials: Systematic Review 4 of the cachexia endpoints series

Significant variation exists in the outcomes used in cancer cachexia trials, including measures of body composition, which are often selected as primary or secondary endpoints. To date, there has been no review of the most commonly selected measures or their potential sensitivity to detect changes resulting from the interventions being examined. The aim of this systematic review is to assess the frequency and diversity of body composition measures that have been used in cancer cachexia trials. MEDLINE, Embase and Cochrane Library databases were systematically searched between January 1990 and June 2021. Eligible trials examined adults (≥18 years) who had received an intervention aiming to treat or attenuate the effects of cancer cachexia for >14 days. Trials were also of a prospective controlled design and included body weight or at least one anthropometric, bioelectrical or radiological endpoint pertaining to body composition, irrespective of the modality of intervention (e.g., pharmacological, nutritional, physical exercise and behavioural) or comparator. Trials with a sample size of <40 patients were excluded. Data extraction used Covidence software, and reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance. This review was prospectively registered (PROSPERO: CRD42022276710). A total of 84 clinical trials, comprising 13 016 patients, were eligible for inclusion. Non-small-cell lung cancer and pancreatic cancer were studied most frequently. The majority of trial interventions were pharmacological (52%) or nutritional (34%) in nature. The most frequently reported endpoints were assessments of body weight (68 trials, n = 11 561) followed by bioimpedance analysis (BIA)-based estimates (23 trials, n = 3140). Sixteen trials (n = 3052) included dual-energy X-ray absorptiometry (DEXA)-based endpoints, and computed tomography (CT) body composition was included in eight trials (n = 841). Discrepancies were evident when comparing the efficacy of interventions using BIA-based estimates of lean tissue mass against radiological assessment modalities. Body weight, BIA and DEXA-based endpoints have been most frequently used in cancer cachexia trials. Although the optimal endpoints cannot be determined from this review, body weight, alongside measurements from radiological body composition analysis, would seem appropriate. The choice of radiological modality is likely to be dependent on the trial setting, population and intervention in question. CT and magnetic resonance imaging, which have the ability to accurately discriminate tissue types, are likely to be more sensitive and provide greater detail. Endpoints are of particular importance when aligned with the intervention's mechanism of action and/or intended patient benefit.

The effects of oral nutritional supplements interventions on nutritional status in patients undergoing colorectal cancer surgery: A systematic review

BACKGROUND

The high incidence of malnutrition in patients undergoing colorectal cancer surgery can lead to unplanned weight loss, sarcopenia and reduced grip strength to the extent that it can seriously affect the prognosis of colorectal cancer patients.

OBJECTIVE

This study investigated the effect of oral nutritional supplements (ONS) on the prevalence of grip strength, unplanned weight loss and sarcopenia in patients undergoing colorectal cancer surgery.

METHODS

We systematically searched randomized controlled studies from CINAHL, PubMed, Embase, Cochrane and Web of Science and three Chinese databases (CNKI, Wan-Fang database, VIP database) from database creation to September 2023. The risk of bias in individual studies was assessed using the Cochrane Collaboration tool, and the certainty of evidence was assessed using the five GRADE criteria. Statistical analysis was performed using the RevMan 5.3 software, and information that could not be meta-analysed was reviewed in the form of a literature summary.

RESULTS

Eleven papers met the inclusion criteria with a combined sample size of 1070 cases, including 532 cases in the trial group and 538 cases in the control group. Four papers reported the effect of ONS on grip strength and included very low-quality evidence supporting no effect of ONS on grip strength. Ten studies reported the effect of ONS on body weight and body mass index (BMI) and included very low-quality evidence supporting a positive ONS on weight and BMI changes. Meta-analysis showed a significant reduction in weight loss (12-15 weeks) and BMI loss (12-15 weeks) in patients with colorectal cancer in the ONS group. The effect of ONS on the prevalence of sarcopenia after hospital discharge was reported in two studies, and meta-analysis showed a significant reduction in the prevalence of postoperative sarcopenia in colorectal cancer patients in the ONS group, but the quality of evidence was low.

CONCLUSIONS

This study showed that the use of ONS in patients undergoing surgery for colorectal cancer improved patient weight loss and BMI reduction and reduced the prevalence of postoperative sarcopenia but did not improve patient grip strength. The quality of evidence for inclusion in the article was low or very low, and further studies are needed to provide better evidence.

Appetite and dietary intake endpoints in cancer cachexia clinical trials: Systematic Review 2 of the cachexia endpoints series

There is no consensus on the optimal endpoint(s) in cancer cachexia trials. Endpoint variation is an obstacle when comparing interventions and their clinical value. The aim of this systematic review was to summarize and evaluate endpoints used to assess appetite and dietary intake in cancer cachexia clinical trials. A search for studies published from 1 January 1990 until 2 June 2021 was conducted using MEDLINE, Embase and Cochrane Central Register of Controlled Trials. Eligible studies examined cancer cachexia treatment versus a comparator in adults with assessments of appetite and/or dietary intake as study endpoints, a sample size ≥40 and an intervention lasting ≥14 days. Reporting was in line with PRISMA guidance, and a protocol was published in PROSPERO (2022 CRD42022276710). This review is part of a series of systematic reviews examining cachexia endpoints. Of the 5975 articles identified, 116 were eligible for the wider review series and 80 specifically examined endpoints of appetite (65 studies) and/or dietary intake (21 studies). Six trials assessed both appetite and dietary intake. Appetite was the primary outcome in 15 trials and dietary intake in 7 trials. Median sample size was 101 patients (range 40-628). Forty-nine studies included multiple primary tumour sites, while 31 studies involved single primary tumour sites (15 gastrointestinal, 7 lung, 7 head and neck and 2 female reproductive organs). The most frequently reported appetite endpoints were visual analogue scale (VAS) and numerical rating scale (NRS) (40%). The appetite item from the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ) C30/C15 PAL (38%) and the appetite question from North Central Cancer Treatment Group anorexia questionnaire (17%) were also frequently applied. Of the studies that assessed dietary intake, 13 (62%) used food records (prospective registrations) and 10 (48%) used retrospective methods (24-h recall or dietary history). For VAS/NRS, a mean change of 1.3 corresponded to Hedge's g of 0.5 and can be considered a moderate change. For food records, a mean change of 231 kcal/day or 11 g of protein/day corresponded to a moderate change. Choice of endpoint in cachexia trials will depend on factors pertinent to the trial to be conducted. Nevertheless, from trials assessed and available literature, NRS or EORTC QLQ C30/C15 PAL seems suitable for appetite assessments. Appetite and dietary intake endpoints are rarely used as primary outcomes in cancer cachexia. Dietary intake assessments were used mainly to monitor compliance and are not validated in cachexia populations. Given the importance to cachexia studies, dietary intake endpoints must be validated before they are used as endpoints in clinical trials.

Body composition change indices combined with Prognostic Nutritional Index predicts the clinical outcomes of patients with gastric cancer treated with immune checkpoint inhibitor

OBJECTIVE

This study aimed to investigate the prognostic significance of the Prognostic Nutritional Index (PNI) in conjunction with body composition change indices, namely subcutaneous fat area (SFA) and skeletal muscle index (SMI), with regard to clinical outcomes in patients with gastric cancer (GC) undergoing immune checkpoint inhibitors (ICIs) treatment.

METHODS

This retrospective investigation encompassed patients with comprehensive clinical and pathological data, inclusive of portal phase enhanced CT images. Continuous variables underwent analysis utilizing the Student t-test or Mann-Whitney U-test, while categorical variables were assessed employing the Pearson chi-squared test or Fisher test. Survival outcomes were evaluated using Kaplan-Meier survival curves and the Log-rank test. Independent prognostic indicators were determined through Cox regression analysis, and a nomogram predicting survival probability for progression-free survival (PFS) and overall survival (OS) was constructed.

RESULTS

Within the PNI-SFA groups, patients in Group 1 exhibited inferior PFS and OS compared to the other two groups. Similarly, among the PNI-SMI groups, Group 1 patients demonstrated poorer PFS and OS. PNI-SMI and Eosi were identified as independent prognostic factors through Cox regression analysis. Furthermore, positive associations with patient prognosis were observed for BMI, SAF, SMI, and PNI.

CONCLUSION

The comprehensive consideration of PNI-SFA and PNI-SMI proved to be a superior prognostic predictor for GC patients undergoing ICI treatment.

Addressing cancer anorexia-cachexia in older patients: Potential therapeutic strategies and molecular pathways

Cancer cachexia (CC) syndrome, a feature of cancer-associated muscle wasting, is particularly pronounced in older patients, and is characterised by decreased energy intake and upregulated skeletal muscle catabolic pathways. To address CC, appetite stimulants, anabolic drugs, cytokine mediators, essential amino acid supplementation, nutritional counselling, cognitive behavioural therapy, and enteral nutrition have been utilised. However, pharmacological treatments that have also shown promising results, such as megestrol acetate, anamorelin, thalidomide, and delta-9-tetrahydrocannabinol, have been associated with gastrointestinal and cardiovascular complications. Emerging evidence on the efficacy of probiotics in modulating gut microbiota also presents a promising adjunct to traditional therapies, potentially enhancing nutritional absorption and systemic inflammation control. Additionally, low-dose olanzapine has demonstrated improved appetite and weight management in older patients undergoing chemotherapy, offering a potential refinement to current therapeutic approaches. This review aims to elucidate the molecular mechanisms underpinning CC, with a particular focus on the role of anorexia in exacerbating muscle wasting, and to propose pharmacological and non-pharmacological strategies to mitigate this syndrome, particularly emphasising the needs of an older demographic. Future research targeting CC should focus on refining appetite-stimulating drugs with fewer side-effects, specifically catering to the needs of older patients, and investigating nutritional factors that can either enhance appetite or minimise suppression of appetite in individuals with CC, especially within this vulnerable group.

Effect of individualized nutritional intervention on head and neck cancer patients receiving radiotherapy

OBJECTIVE

To explore the effect of individualized nutritional interventions on head and neck cancer (HNC) patients receiving radiotherapy and provide a basis for improving the quality of life for those patients.

METHODS

A convenience sampling method was adopted to select HNC patients as the study objects. The Nutritional Risk Screening 2002 scale (NRS2002) was used to screen the nutritional risk in 108 HNC patients receiving radiotherapy, and the patients were randomly divided into control group and observation group. Routine dietary guidance was conducted in the control group, and individualized nutritional intervention was applied in the observation group.

RESULTS

Six months after the intervention, the albumin levels (37.40 ± 4.03 g/L), hemoglobin levels (128.70 ± 15.22 g/L), and body mass index scores (BMI) (23.96 ± 3.23 kg/m2) of the observation group were all better than to those of control group (t = 2.370, 2.216, and 3.135, respectively, and P < 0.05 in all). Six months after the intervention, the anxiety and depression scores in observation group (27.6 ± 7.2 points, 27.3 ± 2.2 points) were lower than those in control group (38.6 ± 9.6 points, 37.9 ± 3.3 points). The quality-of-life score in the observation group was higher than that in control group. The nursing satisfaction in the observation group (96.43%) was higher than that in the control group (75.00%).

CONCLUSION

The implementation of individualized nutritional intervention has promoted the improvement of laboratory indicators, weight, and BMI of head and neck cancer patients, reduced the risk of malnutrition of head and neck cancer patients, improved their quality of life, reduced the occurrence of adverse reactions during radiotherapy, and promoted long-term efficacy.

High Protein Oral Nutritional Supplements Enable the Majority of Cancer Patients to Meet Protein Intake Recommendations during Systemic Anti-Cancer Treatment: A Randomised Controlled Parallel-Group Study

ESPEN guidelines recommend a minimum protein intake of 1.0 g/kg body weight (BW) per day to maintain or restore lean body mass in patients with cancer. During anti-cancer treatment, optimal protein intake is difficult to achieve. We investigated whether a high-protein, low-volume oral nutritional supplement (ONS) supports patients in meeting recommendations. A multi-centre, randomised, controlled, open-label, parallel-group study was carried out in nine hospitals (five countries) between January 2019 and July 2021 in colorectal and lung cancer patients undergoing first-line systemic treatment with chemo(radio-) or immunotherapy. Subjects were randomised (2:1) to receive Fortimel Compact Protein® or standard care. Protein intake was assessed with a 3-day food diary (primary outcome). BW was a secondary outcome. Due to challenges in recruitment, the study was terminated prematurely with 42 patients randomised (intervention group (IG) 28; control group (CG) 14). At T1 and T2, protein intake was statistically significantly higher in the IG compared to the CG (1.40 vs. 1.07 g/kg/day at T1, p = 0.008; 1.32 vs. 0.94 g/kg/day at T2, p = 0.002). At baseline, only 65% (IG) and 45% (CG) of patients met ESPEN minimum protein intake recommendations. However, at T1 and T2 in the IG, a higher proportion of patients met recommendations than in the CG (88% vs. 55% and 40%). No statistically significant difference between study groups was observed for BW. Mean compliance to the ONS was 73.4%. A high-protein, low-volume ONS consumed twice daily enables the majority of patients to reach minimal ESPEN protein recommendations.

Malnutrition in patients with head and neck cancer undergoing radiotherapy: A cross-sectional study

OBJECTIVE

In this study, we investigated the prevalence of malnutrition and analyzed the related factors among patients with head and neck cancer (HNC) undergoing radiotherapy.

METHODS

We included 108 patients with head and neck cancer undergoing radiotherapy from the oncology and thoracic surgery departments of a comprehensive medical center in Qingdao between January 2019 and June 2020. We used the Nutritional Risk Screening-2002 tool (NRS-2002) to evaluate their nutritional status during radiotherapy. We analyzed the basic sociodemographic information and laboratory indicators of the respondents to examine the impact of these factors on nutritional status.

RESULTS

In the 108 patients that we studied, those aged ≥65 years had a significantly higher nutritional risk when compared to patients <65 years of age (P < 0.05). Univariate analysis revealed that a late tumor stage (P = 0.039), the neck being the site of radiotherapy (P = 0.009), the presence of diabetes (P < 0.001), and the presence of anxiety and depression (P = 0.002) were associated with nutritional risks for patients with head and neck cancer undergoing radiotherapy. Multivariate logistic regression analysis identified a late tumor stage, the neck being the radiotherapy site, and combined anxiety and depression as nutritional risk factors in such patients.

CONCLUSION

We found a high incidence of malnutrition in patients undergoing radiotherapy for HNC; this highlights the importance of early identification of patients at risk and evaluation of related risk factors to enhance the efficacy of nutritional interventions.

Effects of food-based interventions in the management of chemoradiotherapy-induced nausea and vomiting: a systematic review

BACKGROUND

Cancer treatment-related nausea and vomiting continue to be common and distressing symptoms for patients, despite improvements in antiemetics. Dietary modifications could potentially improve this symptom experience. Clinicians frequently provide dietary advice to patients, although the evidence base of such suggestions or recommendations is not clear.

PURPOSE

This systematic review aimed to examine the current literature on food interventions associated with improvements in cancer treatment-related nausea and vomiting.

METHODS

Eight electronic databases were searched with a specific search term strategy covering trials without time or language limitations. Eligible studies focused on a food substance, defined as any nutritious substance that people eat or drink to maintain life and well-being. Trials in children and adults during chemotherapy or radiotherapy were included. Cochrane risk of bias tool was used to assess trial quality and GRADE was used to assess the certainty in the effect of each outcome.

RESULTS

Seventeen trials were included, 3 focusing on children and 14 on adults. Two trials included patients receiving radiation. Ten out of 17 trials (59%) had a high risk of bias. Strongest evidence with highest certainty was found for dietary counseling to meet macronutrient requirements in reducing incidence of radiotherapy-related nausea and vomiting in adults (n=2 studies; n=124 participants; GRADE level: moderate). There was also moderate certainty in the beneficial effect of protein supplementation on nausea and vomiting incidence in adults during radiotherapy (n=2 studies; n=124 participants; GRADE level: moderate). A significant positive effect on CINV incidence and/or severity in adults was also found for dietary counseling to meet macronutrient requirements during chemotherapy, a peppermint drink, scaly wood mushroom, chamomile, protein with ginger, and a colorless odorless diet (GRADE level: low to very low).

CONCLUSIONS

The review identified food-based approaches that could improve the nausea and vomiting experience in patients with cancer and provide guidance to clinicians. However, confidence in these findings was low and studies were heterogeneous and mostly of low quality, requiring further investigation before stronger recommendations can be made. Future research is needed to confirm efficacy and safety.

TRIAL REGISTRATION

PROSPERO CRD42022341154.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Predictive validity of GLIM malnutrition diagnosis in patients with colorectal cancer

BACKGROUND

Considering that the validation of the Global Leadership Initiative on Malnutrition (GLIM) remains unclear in patients with colorectal cancer, the present study aimed to assess the agreement, accuracy, sensitivity, specificity, and prognostic effect of the GLIM on survival when compared with the Patient-Generated Subjective Global Assessment (PG-SGA).

METHODS

Patients with colorectal cancer who were scheduled to undergo a routine abdominal computed tomography (CT) scan were recruited. Using the GLIM two-step approach, the patients were first screened for malnutrition by using the PG-SGA Short Form (score ≥3). The malnutrition diagnosis was based on the etiologic (disease burden [cancer] or reduced food intake) and phenotypic GLIM criteria, including weight loss, body mass index, and skeletal muscle index at the third lumbar vertebra when using the CT scans. The food intake was assessed by the PG-SGA.

RESULTS

This study included 191 patients (age, 60.5 ± 11.3 years; 57% men), and 23% and 32% were malnourished according to the GLIM and the PG-SGA, respectively. The GLIM revealed fair sensitivity (64%), good agreement (kappa = 0.65), specificity (96%), and diagnostic accuracy for detecting malnutrition (area under the receiver operating characteristic curve = 0.80; 95% CI, 0.72-0.88) when compared with the PG-SGA. The malnutrition value according to the GLIM and the PG-SGA was associated with short-term survival. However, only the PG-SGA was associated with long-term survival.

CONCLUSIONS

Although showing fair sensitivity, the GLIM had good agreement, specificity, and diagnostic accuracy for malnutrition detection and was an independent predictor of short-term survival in patients with colorectal cancer.

What is hemoglobin, albumin, lymphocyte, platelet (HALP) score? A comprehensive literature review of HALP's prognostic ability in different cancer types

Since its inception, the Hemoglobin, Albumin, Lymphocyte, Platelet Score (HALP) has gained attention as a new prognostic biomarker to predict several clinical outcomes in a multitude of cancers. In our review, we searched PubMed for articles between the first paper on HALP in 2015 through September 2022, yielding 32 studies in total that evaluated HALP's association with various cancers, including Gastric, Colorectal, Bladder, Prostate, Kidney, Esophageal, Pharyngeal, Lung, Breast, and Cervical cancers, among others. This review highlights the collective association HALP has with demographic factors such as age and sex in addition to TNM staging, grade, and tumor size. Furthermore, this review summarizes HALP's prognostic ability to predict overall survival, progression-free survival, recurrence-free survival, among other outcomes. In some studies, HALP has also been able to predict response to immunotherapy and chemotherapy. This review article also aims to serve as a comprehensive and encyclopedic report on the literature that has evaluated HALP as a biomarker in various cancers, highlighting the heterogeneity surrounding HALP's utilization. Because HALP requires only a complete blood count and albumin - already routinely collected for cancer patients - HALP shows potential as a cost-effective biomarker to aid clinicians in improving outcomes for immuno-nutritionally deficient patients.

Food Insecurity Among People With Cancer: Nutritional Needs as an Essential Component of Care

A cancer diagnosis can upend work and family life, leading patients to reallocate resources away from essentials such as food. Estimates of the percentage of people navigating a cancer diagnosis and food insecurity range between 17% and 55% of the cancer patient population. The complexity of addressing food insecurity among those diagnosed with cancer during different phases of treatment is multifactorial and often requires an extensive network of support throughout each phase. This commentary explores the issue of food insecurity in the context of cancer care, explores current mitigation efforts, and offers a call to action to create a path for food insecurity mitigation in the context of cancer. Three programs that address food insecurity among those with cancer at various stages of care are highlighted, drawing attention to current impact and actionable recommendations to make programs like these scalable and sustainable. Recommendations are grounded in the National Academies of Sciences, Engineering, and Medicine social care framework through 5 essential domain areas: awareness, adjustment, assistance, alignment, and advocacy. This commentary seeks to highlight opportunities for the optimization of cancer care and reframe food access as an essential part of treatment and long-term care plans.

Association between malnutrition and leucopenia in patients with osteosarcoma

Background and aim

Leucopenia (LP) greatly limits the efficacy of chemotherapy in osteosarcoma patients. This study aimed to evaluate the nutritional status of osteosarcoma patients before chemotherapy, assess the risk of LP during the perichemotherapy period, and explore the association between malnutrition and LP.

Materials and methods

This study retrospectively analyzed osteosarcoma patients treated in the Tianjin Medical University Cancer Institute and Hospital, China, between January 2009 and December 2020 according to the inclusion and exclusion criteria. Malnutrition in adolescents (5 to 19 years old) and adults (≥20 years old) was diagnosed using WHO AnthroPlus software (version 1.0.4) and Global Leadership initiative on Malnutrition (GLIM), respectively. According to the diagnostic criteria of LP in CTCAE 5.0, patients were divided into the LP group and the non-LP group.

Results

A total of 245 osteosarcoma patients were included. The incidence of malnutrition was 49.0%, and the incidence of LP was 51.8%. The incidence of malnutrition in adolescent patients was 53.1%, and their incidence of LP was 55.2%; the incidence of malnutrition in adult patients was 43.1%, and their incidence of LP was 47.1%. Logistic regression analysis showed that malnutrition before chemotherapy was an independent risk factor for the occurrence of LP after chemotherapy (OR = 6.85, 95% CI = 2.16-25.43; and OR = 35.03, 95% CI = 6.98-238.46 in mildly and severely malnourished young patients; OR = 6.06; 95% CI = 1.43-30.16; and OR = 38.09, 95% CI = 7.23-285.78 in mildly and severely malnourished adult patients, respectively). The results showed that age and nutritional status had a joint effect on the occurrence of LP.

Conclusion

The nutrition status of osteosarcoma patients before chemotherapy is significantly correlated with the occurrence and severity of LP during peri-chemotherapy period. During osteosarcoma chemotherapy, necessary nutritional support should be given to patients of different ages to correct their malnutrition status in a timely manner, ultimately improving the efficacy of chemotherapy and the prognosis of patients.

Does Home Oral Nutritional Support Improve Nutritional Status and Quality of Life following Colorectal Cancer Surgery?

Oral nutritional support (ONS) is a form of supportive intervention in patients' diet in response to insufficient oral intake, malabsorption, or functional insufficient food intake during the disease process. This study aimed to evaluate the nutritional status, morbidity, re-admissions, functional status, QoL of patients who had undergone elective colorectal cancer surgery and initiated home ONS. A total of 144 patients who had undergone colorectal cancer surgery and given home ONS were analyzed with regard to demographics, diagnosis, weight-BMI changes, re-admissions, morbidity, daily caloric and protein intake, functional status (Barthel index) and QoL (The Satisfaction with Life Scale-SWLS). The mean age was 65,6 ± 12,8 with a Female/Male ratio of 53/91. The mean BMI increased from 25.71 ± 3.81 to 28,35 ± 4,53 (p < 0.0001). Re-admission was significantly higher in patients who had received 600 kcal (55.8%) than those who received 900 kcal (40.2%) (p = 0.007). Furthermore, adaptation to chemotherapy (p = 0.02) and the Bartel index scores (p = 0.001) were significantly worse in patients who received 600 kcal compared to patients who received 900 kcal; however, the complication rate (p = 0.84), adaptation to radiotherapy (p = 0.68) and the QoL scores (p = 0.35) were not significantly different. Home ONS improved the BMI in all patients. In addition, ONS resulted in good outcomes with regard to adaptation to chemotherapy and the functional status in the treatments of patients with colorectal cancer.

Nutritional Risk Index Predicts Survival in Patients With Breast Cancer Treated With Neoadjuvant Chemotherapy

Nutritional risk index (NRI) is an index based on ideal body weight that aims to present body weight and serum albumin levels. It has been utilized to discriminate patients at risk of postoperative complications and predict the postoperative outcome of major surgeries. However, this index remains limited for breast cancer patients treated with neoadjuvant chemotherapy (NACT). The research explores the clinical and prognostic significance of NRI in breast cancer patients. This study included 785 breast cancer patients (477 cases received NACT and 308 cases did not) were enrolled in this retrospective study. The optimal NRI cutoff value was evaluated by receiver operating characteristic (ROC) curve, then reclassified as low NRI group (<112) and high NRI group (≥112). The results demonstrated that NRI independently predicted survival on disease-free survival (DFS) and overall survival (OS) by univariate and multivariate Cox regression survival analyses [P = 0.019, hazard ratio (HR): 1.521, 95% CI: 1.071–2.161 and P = 0.004, HR: 1.415, 95% CI: 1.119–1.789; and P = 0.026, HR:1.500, 95% CI: 1.051–2.143 and P < 0.001, HR: 1.547, 95% CI: 1.221–1.959]. According to the optimal cutoff value of NRI, the high NRI value patients had longer mean DFS and OS time in contrast to those with low NRI value patients (63.47 vs. 40.50 months; 71.50 vs. 56.39 months). Furthermore, the results demonstrated that the high NRI score patients had significantly longer mean DFS and OS time than those with low NRI score patients in early-stage breast cancer (χ² = 9.0510, P = 0.0026 and χ² = 9.2140, P = 0.0024) and advanced breast cancer (χ² = 6.2500, P = 0.0124 and χ² = 5.8880, P = 0.0152). The mean DFS and OS values in patients with high NRI scores were significantly longer in contrast to those with low NRI scores in different molecular subtypes. The common toxicities after NACT were hematologic and gastrointestinal reactions, and the NRI had no statistically significant effects on toxicities, except in nausea (χ² = 9.2413, P = 0.0024), mouth ulcers (χ² = 4.8133, P = 0.0282), anemia (χ² = 8.5441, P = 0.0140), and leukopenia (χ² = 11.0951, P = 0.0039). NRI serves as a minimally invasive, easily accessible and convenient prognostic tool for evaluating breast cancer prognoses and treatment efficacy, and may help doctors in terms of selecting measures of greater efficiency or appropriateness to better treat breast cancer.

Validation of the efficacy of the NUTRISCORE for the nutritional screening of cancer patients in China

Background

Malnutrition is common in cancer patients. The NUTRISCORE is a newly developed cancer-specific nutritional screening tool and was validated by comparison with the Patient-Generated Subjective Global Assessment (PG-SGA) and Malnutrition Screening Tool (MST) in Spain. We aimed to evaluate the performance of the NUTRISCORE, MST, and PG-SGA in estimating the risk of malnutrition in Chinese cancer patients.

Methods

Data from an open parallel and multicenter cross-sectional study in 29 clinical teaching hospitals in 14 Chinese cities were used. Cancer patients were assessed for malnutrition using the PG-SGA, NUTRISCORE, and MST. The sensitivity, specificity, and areas under the receiver operating characteristic curve were estimated for the NUTRISCORE and MST using the PG-SGA as a reference.

Results

A total of 1000 cancer patients were included. The mean age was 55.9 (19 to 92 years), and 47.5% were male. Of these patients, 450 (45.0%) had PG-SGA B and C, 29 (2.9%) had a NUTRISCORE ≥5, and 367 (36.7%) had an MST ≥ 2. Using the PG-SGA as a reference, the sensitivity, specificity, and area under the curve values of the NUTRISCORE were found to be 6.2, 99.8%, and 0.53, respectively. The sensitivity, specificity, and area under the curve values of the MST were 50.9, 74.9%, and 0.63, respectively. The kappa index between the NUTRISCORE and PG-SGA was 0.066, and that between the MST and PG-SGA was 0.262 (P < 0.05).

Conclusions

The NUTRISCORE had an extremely low sensitivity in cancer patients in China compared with the MST when the PG-SGA was used as a reference.

Translation, validity, and reliability of NUTRISCORE: the nutrition risk assessment screening test for Turkish cancer patients

PURPOSE

The aim was to determine the validity and the reliability of the Turkish version of the screening test named NUTRISCORE in cancer patients.

METHODS

The language validity of the Turkish form of the study scale was provided by the translationback-translation method. NUTRISCORE and nutritional risk screening (NRS)-2002, malnutrition screening tool (MST), and European Diagnostic Criteria (EDC) were administered to 240 volunteers in oncology clinics, and receiver operating characteristic curves (ROC) were calculated for the validity and reliability analysis. Cohen's kappa coefficient was used to determine the fit between the screening tests.

RESULTS

Thirteen experts were consulted for scale content validity, and the content validity index was found to be 0.94. The scale was administered to 67 patients with 4-week intervals for test-retest reliability, and a positive, high-level and statistically significant relationship was found between the two measurements (r = 0.971, P < 0.01). Compared with the reference test NRS-2002, the specificity values of NUTRISCORE, MST, and EDC screening tests were found to be 100%, 83%, and 91%, whereas the sensitivity values of same screening tests were calculated as 85%, 91% and 81%, respectively. According to Cohen's kappa statistics, the kappa agreement between NRS-2002 and NUTRISCORE was 0.88, the kappa agreement between NRS-2002 and MST was 0.34, and it was found to be 0.73 for NRS-2002 and EDC.

CONCLUSION

The nutrition screening test named NUTRISCORE showed adequate validity and reliability in Turkish and can detect malnutrition risk of cancer patients treated in oncology clinics as a screening tool.

Lactobacillus reuteri Alleviates Gastrointestinal Toxicity of Rituximab by Regulating the Proinflammatory T Cells in vivo

Rituximab (RTX) is a widely used anticancer drug with gastrointestinal side effects, such as nausea, vomiting, and diarrhea. The reason for these side effects is still poorly understood. Previous studies have reported that the intestinal microbiota is associated with the occurrence of disease and the therapeutic effect of drugs. In this study, we observed mucosal damage, inflammatory cell infiltration and increased intestinal inflammatory factor expression in RTX-treated mice. RTX also changed the diversity of the intestinal microbiota in mice, and decreased abundance of Lactobacillus reuteri was observed in RTX-treated mice. Further experiments revealed that intragastric administration of L. reuteri in RTX-treated mice attenuated the intestinal inflammatory response induced by RTX and regulated the proportion of helper T (Th) cells. In conclusion, our data characterize the effect of the intestinal microbiota on RTX-induced intestinal inflammation, suggesting that modifying the gut microbiota may represent a positive strategy for managing adverse reactions.

Self-reported taste and smell alterations and the liking of oral nutritional supplements with sensory-adapted flavors in cancer patients receiving systemic antitumor treatment

PURPOSE

Taste and smell alterations (TAs and SAs) are often reported by patients with cancer receiving systemic antitumor therapy and can negatively impact food intake and quality of life. This study aimed to examine the occurrence of TAs and SAs and investigate the impact of TAs on overall liking of oral nutritional supplements (ONS) with warming and cooling sensations.

METHODS

Patients receiving systemic antitumor therapy completed a questionnaire on sensory alterations and evaluated overall liking of 5 prototype flavors of Nutridrink® Compact Protein (hot tropical ginger (HTG), hot mango (HM), cool red fruits (CRF), cool lemon (CL), and neutral (N)) on a 10-point scale via a sip test. Differences between patients with and without TAs were investigated using permutation analysis.

RESULTS

Fifty patients with various cancer types and treatments were included. Thirty patients (60%) reported TAs and 13 (26%) experienced SAs. Three flavors were rated highly with a liking score > 6 (CRF 6.8 ± 1.7; N 6.5 ± 1.9; HTG 6.0 ± 2.0). Larger variation in ONS liking scores was observed in patients with TAs with or without SAs (4.5-6.9 and 4.6-7.2, respectively) vs. patients without TAs (5.9-6.5). TAs were associated with increased liking of CRF (Δ = + 0.9) and N (Δ = + 1.0) flavors.

CONCLUSIONS

TAs and SAs are common in patients with cancer undergoing systemic antitumor therapy. Patients with TAs were more discriminant in liking of ONS flavors compared to patients without TAs, and sensory-adapted flavors appeared to be appreciated. The presence of TAs should be considered when developing or selecting ONS for patients with cancer.

TRIAL REGISTRATION

Registration at ClinicalTrials.gov (NCT03525236) on 26 April 2018.

Impact of an Oral Nutritional Protocol with Oligomeric Enteral Nutrition on the Quality of Life of Patients with Oncology Treatment-Related Diarrhea

(1) Background: Nutritional status can influence the quality of life (QoL) of cancer patients. (2) Methods: This subanalysis evaluated the impact of an oral oligomeric enteral nutrition (OEN) protocol on the QoL of patients with oncology treatment-related diarrhea (OTRD) in a multicenter, observational, prospective study (DIAPOENO study). QoL was assessed with the Nottingham Health Profile (NHP) at baseline and after eight weeks of OEN treatment. (3) In the overall population, all the NHP categories significantly improved after eight weeks of OEN treatment: energy levels (p < 0.001), pain (p < 0.001), emotional reactions (p < 0.001), sleep (p < 0.001), social isolation (p = 0.023), and physical abilities (p = 0.001). QoL improvement was higher in patients with improved or maintained nutritional status and in those with improved consistency of stools with the OEN protocol. However, QoL did not significantly improve in patients with worse nutritional status and with worse or maintained stool consistency with the OEN protocol. QoL improved regardless of disease severity. Multivariate logistic regression analysis showed that weight change was significantly associated with improved QoL (OR 2.90-5.3), except for social isolation, in models unadjusted and adjusted to age, sex, oncology treatment, and stool consistency. (4) Conclusion: In this subanalysis, the OEN protocol was associated with improved QoL.

Cooking for Vitality: Pilot Study of an Innovative Culinary Nutrition Intervention for Cancer-Related Fatigue in Cancer Survivors

(1) Background: Cancer-related fatigue (CRF) is one of the most prevalent and distressing side effects experienced by patients with cancer during and after treatment, and this negatively impacts all aspects of quality of life. An increasing body of evidence supports the role of poor nutritional status in the etiology of CRF and of specific diets in mitigating CRF. We designed a group-based two session culinary nutrition intervention for CRF, Cooking for Vitality (C4V), aimed at increasing understanding of how food choices can impact energy levels and establishing basic food preparation and cooking skills as well as the application of culinary techniques that minimize the effort/energy required to prepare meals. The purpose of this pilot mixed-method study was to evaluate: Feasibility of the experimental methods and intervention; acceptability and perceived helpfulness of intervention; and to obtain a preliminary estimate of the effectiveness of the intervention on fatigue (primary outcome), energy, overall disability, and confidence to manage fatigue (secondary outcomes). (2) Methods: Prospective, single arm, embedded mixed-methods feasibility study of cancer survivors with cancer-related fatigue was conducted. Participants completed measures at baseline (T0), immediately following the intervention (T1), and three months after the last session (T2). Qualitative interviews were conducted at T2. (3) Results: Recruitment (70%) and retention (72%) rates along with qualitative findings support the feasibility of the C4V intervention for cancer survivors living with CRF (program length and frequency, ease of implementation, and program flexibility). Acceptability was also high and participants provided useful feedback for program improvements. Fatigue (FACT-F) scores significantly improved from T0–T1 and T0–T2 (p < 0.001). There was also a significant decrease in disability scores (WHO-DAS 2.0) from T0–T2 (p = 0.006) and an increase in POMS-Vigor (Profile of Mood States) from T0–T1 (p = 0.018) and T0–T2 (p = 0.013). Confidence in managing fatigue improved significantly from T0–T1 and T0–T2 (p < 0.001). (4) Conclusions: The results suggest that the C4V program was acceptable and helpful to patients and may be effective in improving fatigue levels and self-management skills. A randomized controlled trial is required to confirm these findings.

Nutritional status and interventions for patients with cancer - A systematic review

BACKGROUND

Malnourishment is commonly seen in ageing, cancer and many chronic conditions, and is associated with poorer prognosis.

AIM

We set out to collect all currently available evidence on the association between nutritional status assessed with a validated screening tool and prognosis or course of treatment in older patients with cancer, and on the benefit of nutritional interventions in improving these outcomes.

METHODS

A systematic search in MEDLINE and EMBASE.

RESULTS

We included 71 studies on the association between nutritional status and outcome in (older) patients with cancer and 17 studies on the benefit of nutritional interventions in improving outcomes in this patient population. There is a significant association between nutritional status and increased intermediate- and long-term mortality (hazard ratio 1.87 (95% confidence interval 1.62-2.17). Those with poorer nutritional status were less likely to complete oncologic treatment according to plan and had higher health care consumption. Benefit of dietary interventions was limited although dietary counselling may lead to improved quality of life while nutritional support may lead to a decrease in post-operative complication rates.

CONCLUSION

Nutritional status is associated with poorer survival, decreased treatment completion and higher health care consumption and nutritional interventions are only able to negate these negatives outcome to a very limited degree.

Nutrition interventions to improve the appetite of adults undergoing cancer treatment: a systematic review

PURPOSE

Loss of appetite is a common side effect of cancer and cancer treatments resulting in risk of malnutrition and cancer cachexia. This review aimed to systematically determine nutrition interventions that improve appetite and nutrition-related outcomes of adults with cancer undergoing cancer treatments, and to identify appetite assessment tools used to measure appetite.

METHODS

Inclusion criteria included randomised controlled trials of adults with cancer undergoing chemotherapy, radiotherapy or immunotherapy treatments, nutrition interventions and appetite assessed by an appetite assessment tool or quality of life tool. The search strategy was applied to four databases and two researchers systematically assessed for eligibility. Following data extraction, quality of the included library was assessed using the Quality Criteria Checklist: Primary Research. A narrative synthesis of results was undertaken.

RESULTS

After title/abstract screening, 24 full texts were assessed for eligibility; five trials of n = 472 participants were included in the final library. Nutrition interventions that improved appetite were oral nutrition supplements, fish oil supplements and dietary counselling. Appetite was assessed via visual analogue scales (n = 1) and EORTC QLQ C30 questionnaire (n = 4). Quality was assessed as neutral in 2 studies and positive in 3 studies.

CONCLUSION

The use of oral nutrition supplements and dietary counselling and increases in EPA from fish oil supplementation improved the appetite and nutrition outcomes of patients with cancer undergoing cancer treatments. Validated assessment tools in the oncology setting are needed to determine which nutrition interventions positively influence appetite outcomes.

Prevotella copri is associated with carboplatin-induced gut toxicity

As a widely used cancer drug, carboplatin often results in serious side effects, such as gut toxicity. In this study, we examined the effects of gut microbiota on mice with carboplatin-induced intestinal mucosal damage. Carboplatin resulted in intestinal mucositis, as indicated by weight loss, diarrhoea, and infiltration of inflammatory cells. It markedly increased the expression of inflammatory cytokines/chemokines in intestine. Carboplatin also altered the diversity and composition of the gut microbiota. A significantly higher abundance of Prevotella copri (P. copri) was observed in carboplatin-treated mice. Moreover, the content of P. copri was positively correlated with the severity of intestinal mucositis. Pretreatment with metronidazole reduced the content of P. copri and relieved the intestinal mucosal injury and inflammation that was induced by carboplatin. Further study revealed that supplementation with P. copri in carboplatin-treated mice resulted in more severe tissue damage, lower tight junction protein expression and higher cytokine expression, and it enhanced both local and systemic immune responses. These data demonstrated that P. copri was involved in the pathological process of carboplatin-induced intestinal mucositis, suggesting a potential attenuation of carboplatin-induced intestinal mucositis by targeting P. copri.

Systemic prognostic score and nomogram based on inflammatory, nutritional and tumor markers predict cancer-specific survival in stage II-III gastric cancer patients with adjuvant chemotherapy

BACKGROUND

To investigate the clinical utility of several established inflammatory, nutritional and tumor markers, and to construct a new scoring system based on preoperative prognostic markers to predict outcomes in gastric cancer (GC).

METHODS

We retrospectively assessed 688 consecutive patients who underwent curative resection followed by adjuvant chemotherapy for stage II-III GC from 2000 to 2012.

RESULTS

On multivariate analysis, C-reactive protein/albumin (CRP/Alb) ratio (>0.2), prognostic nutritional index (PNI) (score 1), preoperative body weight loss (>6%) and carbohydrate antigen 19-9 (CA 19-9) (>27 U/mL) independently predicted unfavorable cancer-specific survival (CSS). These 4 preoperative prognostic markers were allocated 1 point each. Then, a new systemic prognostic score (SPS) was constructed based on the total score. Multivariate analysis revealed that SPS was an independent predictor of CSS (P < 0.001). Patients with a SPS of 0, 1, 2, or 3/4 had a 5-year CSS rates of 67.2%, 45.3%, 29.0%, and 10.6%, respectively (0 vs. 1 [P < 0.001], 1 vs. 2 [P = 0.031] and 2 vs. 3/4 [P = 0.004]). The median survival times for SPS 0, SPS 1, SPS 2 and SPS 3/4 were 68.7, 47.1, 28.3 and 16.3 months, respectively. The area under the receiver operating characteristics (ROC) curve for SPS was higher than other markers (P < 0.001). Furthermore, a nomogram that integrated TNM stage, tumor location and SPS exhibited superior discrimination power compared with the TNM stage alone (C-index, 0.714 vs. 0.630, respectively; P < 0.001).

CONCLUSION

The preoperative SPS combining inflammatory, nutritional and tumor markers independently predicted postoperative survival in stage II-III GC patients treated with adjuvant chemotherapy.

Is cachexia associated with chemotherapy toxicities in gastrointestinal cancer patients? A prospective study

BACKGROUND

Chemotherapy is an effective treatment with good clinical response in patients with cancer. However, it can cause exacerbated toxicities in patients and consequently change the course of treatment. Some factors may interfere with this toxicity such as body composition, especially in gastrointestinal cancer. The aim of this study was to evaluate the effects of body composition, nutritional status, and functional capacity scale in predicting the occurrence of toxicities in gastrointestinal cancer patients during chemotherapy treatment.

METHODS

This is a prospective study with gastrointestinal cancer patients at the beginning of chemotherapy treatment. Sarcopenia and muscle attenuation were assessed using the skeletal muscle index from computerized tomography by measuring cross-sectional areas of the L3 tissue (cm² /m² ). Cachexia was graded according to involuntary weight loss associated with sarcopenia. Nutritional status was assessed by using anthropometric evaluation and Patient-Generated Subjective Global Assessment. Functional capacity was evaluated by handgrip strength and Eastern Cooperative Oncology Group (ECOG) Performance Status scale. Haematological gastrointestinal and dose-limiting toxicities (DLTs) were defined according to National Cancer Institute Common Toxicity Criteria. The associations among sarcopenia, cachexia, nutritional status, and functional capacity with DLT were assessed by univariate and multivariate Cox regression model.

RESULTS

A total of 60 patients were evaluated (55% male, 60.9 ± 14.0 years) and followed up for a mean of 55 days. Most patients had normal weight (44.2%) and good ECOG Performance Status (≤1) at baseline (78%). During the chemotherapy period, the most prevalent toxicities were diarrhoea, nausea, and anorexia, but the presence of DLT was similar between cycles (P > 0.05). Cachexia was associated with a higher toxicity manifested by diarrhoea (P = 0.02), nausea (P = 0.02), and anorexia (P < 0.01 and P = 0.03 at Cycles 1 and 2, respectively). Sarcopenic and cachetic individuals experienced more toxicities and DLT during chemotherapy. The only factors associated with DLT in the multivariate Cox regression analyses including the presence of metastasis and the chemotherapy protocol were cachexia and the ECOG scale (P < 0.001 for both).

CONCLUSIONS

Cachexia and ECOG score may identify patients with an increased risk for developing severe toxicity events during chemotherapy treatment for gastrointestinal cancer.

Nutritional Interventions for Treating Cancer-Related Fatigue: A Qualitative Review

Cancer-related fatigue (CRF) is a debilitating syndrome that persists for many cancer survivors for years after treatment. Symptoms include early and persistent fatigue, functional decline, depression, and cognitive difficulties. Inflammation, assessed using pro-inflammatory biomarkers, is increased in cancer survivors with fatigue and treatments for fatigue are often aimed at reducing inflammation. Additionally, cancer and its treatment lead to nutritional complications, changes in body composition, and nutritional deficiencies that potentially weaken the cancer survivor and impact CRF. We conducted a qualitative review of clinical trials that assessed nutritional interventions for preventing and treating CRF. Further studies were examined that used nutritional interventions to address inflammation and fatigue, due to the dearth of nutrition research directly related to CRF. Dietary intake prior to, during, and after cancer treatment appears to affect fatigue levels. Increased protein intake may help preserve lean mass and body composition. Dietary patterns that reduce inflammation, such as the Mediterranean diet and other plant-based diets, appear tolerable to cancer survivors and may reduce fatigue. Supplementation with ginseng, ginger, or probiotics may improve cancer survivors' energy levels. Nutritional interventions, alone or in combination with other interventions should be considered as therapy for fatigue in cancer survivors.