The relationship between nutritional status and prognosis in advanced cancer patients in palliative care: a retrospective study

doi:10.21203/rs.3.rs-1744433/v1

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The relationship between nutritional status and prognosis in advanced cancer patients in palliative care: a retrospective study

https://doi.org/10.21203/rs.3.rs-1744433/v1

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Purpose The study aimed to determine the severe nutritional status, related factors, and its effect on the prognosis of patients with advanced cancer.

Methods The study consisted of 208 patients. The nutritional status of the patients was evaluated by the biochemical factors (serum albumin, transferrin and hemoglobin levels), anthropometric parameters (body weight change and BMI), questionnaires (PG-SGA) and physical activity (KPS). Severe nutritional status was diagnosed with the PG-SGA score of ≥9. The factors related to nutritional status were determined using a logistic regression analysis. Kaplan-Meier survival analysis and the log-rank test were used to calculate OS. The effect of poor nutritional status on survival was performed by Cox regression analysis.

Results The median age was 64 years (28–89). Severe nutritional status was found in 56.4% of patients according to PG-SGA. The factors associated with severe nutritional status according to PG-SGA were age, BMI＜18.5 kg/m², KPS < 80, anemia, nutrition impact symptoms (loss of appetite, sleep disturbance, constipation and weight loss), pre-albumin＜200mg/L, albumin＜35g/L, and CRP≥10mg/L. The median overall survival significantly decreased with severe nutritional status according to PG-SGA (p < 0.011), fatigue (p = 0.039), weight loss (p = 0.009) and cancer type (p = 0.026).

Conclusion Severe nutritional status is a common factor associated with poor prognosis in advanced cancer patients. Patients should be assessed for nutritional status and supported.

Advanced cancer

Nutritional status

PG-SGA

Prognosis

Survival

Palliative care is a health care approach that aims to improve the quality of life for advanced cancer patients/families, focusing on management of pain and other distressing symptoms, and psychological, spiritual and social support. The practice of palliative care should be taken by collaboration with an interdisciplinary team of experts(National Comprehensive Cancer Network, 2022). Accurate prediction of survival for advanced cancer patients is critical since many clinical and personal decisions are driven by patient life expectancy. Prognostic assessment minimizes the risk of undertreatment or disproportionate therapies in advancing cancer(Hui et al., 2019). Among the various predictors of survival, impaired nutritional status, exacerbated systemic inflammation and reduced immune function have been recognized as useful prognostic indicators in clinical practice(Silva et al., 2020; Cordeiro LAF et al., 2020). Cancer patients have been identified to be one of the highest prevalent groups of malnourished patients(Ryan AM et al., 2019). Malnutrition is more highly prevalent in patients with cancer at advanced stages rather than early stages(Arends et al., 2017).

Numerous studies have highlighted the consequences of cancer-related malnutrition, including negative impact on clinical outcomes and added healthcare costs. In terms of poor clinical outcomes, malnutrition was related to loss of weight and muscle(Gellrich et al., 2015), reduced immune competence(Bullock et al., 2020), psychosocial stress [24], lower quality of life(Sonneborn-Papakostopoulos et al., 2021), greater risk of mortality and decreases survival rate(Yan et al., 2021; Gul et al., 2021). Furthermore, the relative risk of death from malnutrition has been found to be 1.8 times higher than for cancer patients without malnutrition(Datema et al., 2011). In terms of outcomes that affect healthcare costs, length of stay in hospital was longer in malnourished patients with cancer(Maasberg et al., 2017; Planas et al., 2016) and overall hospitalization costs were increased. Hence, it is essential to consider nutritional status during palliative care.

Some biochemical factors, including prealbumin, serum albumin and hemoglobin levels and anthropometric parameter, such as body weight change and body mass index (BMI) have been employed to assess the nutrition status in cancer patients. Based on laboratory tests and anthropometric indicators, nutritional assessment scale should be comprehensively used to assess nutritional status among cancer patients. The scored PG-SGA has been accepted by the Oncology Nutrition Dietetic Practice Group of the American Dietetic Association as the standard for nutrition assessment for patients with cancer. It contains additional problems regarding the existence of nutritional symptoms and short-term weight loss.

The present retrospective study comprises two main purposes. First, we aim to determine the poor nutritional status and associated factors in patients with advanced cancer. Second, we aim to assess the effect of nutritional indicators on prognosis.

Study group

A retrospective study design was conducted from February 2020 to January 2021 in the Palliative Care department at Fudan University Shanghai Cancer Center, China. A purposive sample composed of 221 patients aged 18 years or above. Cancer patients with metastatic or locally advanced tumors were eligible for inclusion if they had a Karnofsky Performance Status (KPS) of 30%, able to adequately answer the necessary information and underwent treatment and follow-up. Exclusion criteria include patients during the study years but not followed; patients with incomplete treatment and surveillance records. Thirteen patients with unknown histopathology were excluded from the study, and 208 patients were analyzed. Fudan University Cancer Center Human Research Ethics Committee reviewed and approved the study (No: 2103232-26).

Study variables and definitions

Demographic characteristics included gender, age, educational level, marital status. Clinical characteristics were obtained by consulting medical records, as follows: histopathology, stage at diagnosis, symptoms related to nutrition (pain, fatigue, abdominal distension, loss of appetite, dyspnea, sleep disturbance, nausea and vomiting, constipation, weight loss), comorbidities, anemia, KPS, BMI, laboratory indexes and pathological diagnosis time.

The outcome variable was the overall survival (OS) time. OS was defined as the time from the date of pathological diagnosis to the date of death or the most recent follow-up.

Nutritional status assessment: The Chinese version of the Patient-Generated Subjective Global Assessment (PG-SGA) was used after permission. The PG-SGA is validated nutritional assessment tool for cancer patients, which is made up of both patient-reported and professional-assessed items. The total PG-SGA score is the sum of scores of the following seven items-weight loss, disease, food intake, nutrition impact symptoms, activities and function, metabolic demand, and physical examination. Based on these assessments, patients are classified as well-nourished (PG-SGA: A), moderately or suspected of being malnourished (PG-SGA: B), or severely malnourished (PG-SGA: C). And, nutrition support schemes of patients as follows: 0–1, nutritional support not required and treatment in the future based on routine re-evaluation; 2–3, dietary guidance for patients and their families by a nutritionist, with assistance from nurses or other health care professionals based on symptom investigation and laboratory examination; 4–8, nutritional support provided by a dietitian with assistance from nurses or physicians according to the symptom questionnaire; ≥9, urgent need for improved symptom management and/or nutritional support. The higher the PG-SGA score, the worse the nutritional status(Vigano et al., 2014). It was collected within 24 hours of the hospital admission to the unit. For the PG-SGA data, patients in categories B and C were classified as malnourished, and those in category A as well-nourished. It requires experienced assessors to obtain consistent and reliable results.

Statistical Analysis

Data analysis were performed using SPSS software (version 22.0; IBM, Armonk, NY, USA). Data were presented using descriptive statistics in the form of frequencies and percentages. The degree of relationship among these factors and PG-SGA scores was statistically evaluated using the Chi-square test (gender, marital, educational level, pathology, comorbidities, anemia and symptoms related to nutrition), Wilcoxon signed-rank test (age, stage, albumin, pre-albumin and C-reactive protein [CRP]), and Wilcoxon test (BMI, KPS). OR and 95% confidence interval (CI) were calculated by univariate logistic regression analysis. Kaplan-Meier curves were used to plot the distribution of OS by group. The Log-Rank tests were conducted to compare the survival of patients among subgroups. Multivariate Cox regression survival analyses were performed to identify the independent association of all clinical features with survival. The minimum numbers of independently significant variables were determined by backward stepwise variable selection in the multivariate Cox regression survival analysis.

Characteristics of study group

The study group consisted of 208 patients with advanced cancer patients. The age of the study group ranged from 28 to 89 years, with a mean±SD of 62.7±10.978 and a median of 64 years. Of the patients in this study, 51.4% (107) were male, 48.6% (99) were secondary school, 97.6% (203) were married. 59.6% (124) of the patients had a pathological diagnosis of GI tract cancer. Patients with TNM stage IVA-IVB constituted 70.7% (147). Descriptive characteristics of the study group are presented in Table 1.

Table 1

Characteristics of the study group
Variables	N	%
Age(years)
<65	106	51.0
≥ 65	102	49.0
Gender
Male	107	51.4
Female	101	48.6
Educational level
Illiteracy	10	4.8
Read & Write	15	7.2
Primary	72	34.6
Secondary	99	47.6
Bachelor	12	5.8
Marital status
Married	203	97.6
other	5	2.4
Cancer type
GI tract	124	59.6
Lung	22	10.6
Breast	22	10.6
Gynecological	18	8.7
Urologic	12	5.8
HN	5	2.4
Other	5	2.4
Stage
IIIB-IIIC	61	29.3
IVA-IVB	147	70.7
Comorbidities
Yes	83	39.9
No	125	60.1
BMI(kg/m²)
<18.5	110	52.9
≥ 18.5 and<25.0	79	38.0
≥ 25.0	19	9.1
Anemia
Yes	138	66.3
No	70	33.7
Pain
Yes	120	57.7
No	88	42.3
Variables	N	%
Fatigue
Yes	95	45.7
No	113	54.3
Abdominal distension
Yes	41	19.7
No	167	80.3
Loss of appetite
Yes	123	59.1
No	85	40.9
Dyspnea
Yes	7	3.4
No	201	96.6
Sleep disturbance
Yes	110	52.9
No	98	47.1
Nausea and vomiting
Yes	12	5.8
No	196	94.2
Constipation
Yes	127	61.1
No	81	38.9
Weight loss
Yes	103	49.5
No	105	50.5
KPS
<80	173	83.2
≥ 80	35	16.8
Pre-albumin(mg/l)
<200mg/L	170	81.7
≥ 200mg/L	38	18.3
Albumin(g/L)
<35g/L	124	59.6
≥ 35 g/L	84	40.4
CRP(mg/L)
<10 mg/L	49	23.6
≥ 10 mg/L	159	76.4
Survival status
Exitus	127	61.1
Alive	81	38.9

Notes: KPS: Karnofsky performance status; GI tract: gastrointestinal tract.

Severe malnutrition and related factors in the study group

In the study, one nutritional indicator (PG-SGA) was obtained by using the nutritional parameters of patients. PG-SGA scores ranged from 1 to 27, with a mean of 12.32±6.078 and a median of 12 in advanced cancer patients. According to the PG-SGA score, 62.5% (130) of patients had severe malnutrition status. Table 2 summarizes the nutritional status of the study group. Participants received corresponding nutrition intervention based on the PG-SGA score after completing the PG-SGA.

Table 2

Patient-Generated Subjective Global Assessment classification (N = 208)
Classification (score)	Cases(n)	%
PG-SGA A: Without intervention (0–1)	3	1.4
PG-SGA B: Need health education (2–3)	26	12.5
PG-SGA B: Need nutritional support (4–8)	49	23.6
PG-SGA C: Need symptom management and/or nutritional support (≥ 9)	130	62.5

Severe nutritional status among advanced cancer patients was severer in the age group of ≥ 65 years than those < 65 years (p = 0.001) in BMI<18.5 kg/m² than ≥ 18.5 and<25.0 kg/m² or ≥ 25.0 kg/m² (p = 0.001) and in KPS<80 than ≥ 80 (p = 0.000). It was also severer in patients who has anemia (p = 0.018), pain (p = 0.025), loss of appetite (p = 0.000), sleep disturbance (p = 0.008), constipation (p = 0.037) and weight loss (p = 0.019) than those without (Table 3). In addition, poor nutritional status was higher in patients who have pre-albumin < 200mg/L (p = 0.006), albumin<35g/L (p = 0.001), and CRP ≥ 10mg/L (p = 0.000) than others (Table 3).

Table 3

Demographic Characteristics of the Patients and its Relation to their Nutritional Status (N = 208)
Variables	Total PG-SGA assessment score				p-value
	PG-SGA<9 (n = 78)		PG-SGA ≥ 9 (n = 130)
	N	%	N	%
Age(years)					0.001^b
<65	39	69.6	67	44.1
≥ 65	17	30.4	85	55.9
Gender					0.493^*
Male	31	55.4	76	50.0
Female	25	44.6	76	50.0
Educational level					0.933^*
Illiteracy	2	3.6	8	5.3
Read & Write	5	8.9	10	6.6
Primary	19	33.9	53	34.9
Secondary	26	46.4	73	48.0
Bachelor	4	7.1	8	5.3
Marital status					1.000^*
Married	55	98.2	148	97.4
other	1	1.8	4	2.6
Cancer type					0.797^*
GI tract	35	62.5	89	58.6
Lung	6	10.7	16	10.5
Breast	6	10.7	16	10.5
Gynecological	6	10.7	12	7.9
Urologic	2	3.6	10	6.6
HN	1	1.8	4	2.6
Other	0	0.0	5	3.3
Stage					0.220^b
IIIB-IIIC	20	35.7	41	27.0
IVA-IVB	36	64.3	111	73.0
Co-morbidities					0.454^*
Yes	20	35.7	63	41.1
No	36	64.3	89	58.6
Anemia					0.018^*
Yes	30	53.6	108	71.1
No	26	46.4	44	28.9
BMI(kg/m²)					0.001^b
<18.5	7	12.5	103	67.8
≥ 18.5 and<25.0	38	67.9	41	27.0
≥ 25.0	11	19.6	8	5.3
Pain					0.025^*
Yes	6	10.7	114	75.0
No	50	89.3	38	25.0
Fatigue					0.262^*
Yes	22	39.3	73	48.0
No	34	60.7	79	52.0
Abdominal distension					0.423^*
Yes	9	16.1	32	21.1
No	47	83.9	120	78.9
Loss of appetite					0.000^*
Yes	22	39.3	101	66.4
No	34	60.7	51	33.6
Dyspnea					0.739^*
Yes	1	1.8	6	3.9
No	55	98.2	146	96.1
Sleep disturbance					0.008^*
Yes	8	14.3	102	67.1
No	48	85.7	50	32.9
Nausea and vomiting					0.246^*
Yes	1	1.8	11	7.2
No	55	98.2	141	92.8
Constipation					0.037^*
Yes	4	7.1	123	80.9
No	52	92.9	29	19.1
Weight loss					0.019^*
Yes	13	23.3	90	59.2
No	43	76.8	62	40.8
KPS					0.000^b
<80	32	57.1	143	94.1
≥ 80	24	42.9	9	5.9
Pre-albumin(mg/l)					0.006^b
<200mg/L	39	69.6	131	86.2
≥ 200mg/L	17	30.4	21	13.8
Albumin(g/L)					0.001^b
<35g/L	23	41.1	101	66.5
≥ 35g/L	33	58.9	51	33.6
CRP(mg/L)					0.000^b
<10mg/L	25	44.6	24	15.8
≥ 10mg/L	31	55.4	128	84.2

Notes: PG-SGA=Patient-Generated Subjective Global Assessment; BMI=body mass index; GI=gastrointestinal; CRP=C-reactive protein.

^aMean chi-square test. ^b Mean Wilcoxon signed-rank test.

p < 0.05 are italized.

In the logistic regression model, the factors associated with severe nutritional status according to PG-SGA were age, pain, loss of appetite, nausea and vomiting, constipation, weight loss, KPS in advanced cancer patients (Table 4).

Table 4

Factors related to severely malnourished according to PG-SGA in multivariate logistic regression model
Variables	OR	95%CI	p
Age	3.086	1.442–6.603	0.004
Pain	0.403	0.146–1.109	0.078
Loss of appetite	0.484	0.232–1.011	0.053
Nausea and vomiting	0.239	0.027–2.149	0.201
Constipation	0.376	0.115–1.223	0.104
Weight loss	0.475	0.208–1.087	0.078
KPS	0.137	0.052–0.355	0.000

Notes: OR=odds ratio; CI=confidence interval

Relationship between nutritional status and survival

The mean and median OS time (standard error) and 95%CI in the advanced cancer patients were 42.6 (3.3) (36.1–49.1) and 29.0 (2.5) (24.0–34.0) months. 38.9% (81) patients were alive at the end of the study.

According to the PG-SGA score, the median OS time (95%CI) in patients with normal or moderately or suspected nutritional status, and severe were 67.0 (48.1–85.9), and 26.0 (21.8–30.2) months, respectively. As the level of nutritional deficiency increased, life expectancy decreased significantly (log-rank = 11.84; p < 0.001). (Fig. 1). In age- and sex-matched analysis, the PG-SGA scores were still associated with OS (p = 0.001, respectively; Fig. 2).

The median OS time was related to fatigue (p = 0.039), weight loss (p = 0.009), cancer type (p = 0.026), in the advanced cancer patients. Multiple Cox regression analysis was performed by considering the confounding factors to determine the effect of nutritional status on OS in patients. Severely nutritional status according to PG-SGA was an independent prognostic factor. Multiple Cox regression analysis results are presented in Table 5.

Table 5

Factors related to survival time of the patients in multivariate model
Variables	HR	95%CI	p
Gender	0.724	0.507–1.034	0.076
Fatigue	0.679	0.470–0.980	0.039
Weight loss	1.722	1.148–2.584	0.009
KPS	0.596	0.323–1.099	0.098
Cancer type	0.877	0.781–0.984	0.026
Plus
PG-SGA(<9 vs ≥ 9)	1.935	1.164–3.218	0.011

Despite the remarkable advances in the treatment of cancers and survival for all cancers increased in recent years, patients with locally advanced and advanced stage cancer still have poor survival time. The study included locally advanced and advanced stage cancer patients. During the latest period, the 5-year survival rate of all cancer patients varies between 46.9% and 68.0% for men, and for women, survival ranged between 52.7% and 66.6%(Santucci et al., 2020). Incidence trends are different for men and women and primarily reflect cultural and regional differences. China is undergoing a transition toward the cancer profiles in developed counties, characterized by high incidence of cancers of the lung, colorectum, breast, prostate and decreasing cancer burden in liver, stomach, and esophagus. Population aging is a growing determinant of incremental cancer burden(Xia et al., 2022). In the study, it was shown that severe nutritional status affects the prognosis of patients with advanced cancer regardless of histopathology, fatigue and weight loss.

The results of our study (Table 2) showed that 62.5% of the patients need nutrition-related symptom management and/or nutritional support urgently. Moreover, only 1.4% of the advanced cancer patients do not need nutritional intervention. Our study reveals that malnutrition is prevalent in advanced cancer patients, and these patients require timely nutrition education and guidance, treatment for symptoms, such as antitumoral treatment, and proper nutritional support.

Nutritional status has been employed to assess in a range of ways including biochemical factors (serum albumin, transferrin and hemoglobin levels), anthropometric parameters (body weight change and BMI), questionnaires and physical activity (KPS) in cancer patients(Pan et al., 2021; Zhang et al., 2021; Qiao et al., 2020). However, conventional nutritional assessment tools are not useful in most patients with advanced cancer, because they can give false results, have high costs for routine use, and have limited merit to assess debilitated patients(Pastore et al., 2014). There is no recommended indicator to detect nutritional status for routine practice. PG-SGA was recognized as the most efficient and specific tool for screening and evaluating cancer patients(Jager-Wittenaar & Ottery, 2017; Barata et al., 2017). Therefore, nutritional status was assessed by hemo-biological indices (hemoglobin, albumin, prealbumin, CRP), BMI and PG-SGA in the study. These indices are routine biochemical parameters without additional costs for the patient.

Anemia is a common symptom in cancer patients. The association between decreased hemoglobin levels and poor quality of life has been demonstrated by randomized and controlled trials(Sjoquist et al., 2018). The low level of hemoglobin is correlated with a poor response to treatment and deteriorates survival, especially in patients with late-stage disease(Wang & Shao, 2018). The present findings have demonstrated that anemia in cancer patients predicts for worse tumor regression, prognosis and overall survival by exacerbating tumor hypoxia, even though the anemia is often mild(McGrane et al., 2017). The ‘low oxygen tension’ within tumor bed promotes angiogenesis and formation of mutated tumor cell lines capable of surviving at low levels of oxygen. Anemia is associated with larger tumors of higher stage and anemia-induced tumor hypoxia precipitates more aggressive tumor phenotypes with greater levels of circulating angiogenic factors(Khan AA et al., 2013). If anemia plays an independent role in determining the efficacy of advanced tumors, pretreatment optimization of hemoglobin levels could lead to improved clinical outcomes.

As common predictors of nutritional status, serum albumin, and prealbumin are closely related to post-treatment morbidity and mortality of patients with various tumors(Pan et al., 2021; Qiao et al., 2020). Serum albumin, the most common blood protein synthesized in the liver, has been generally used to assess nutritional status and visceral protein synthesis function. Low levels of serum albumin have also been determined to be an independent risk factor for survival in pancreatic cancer patients. Albumin plasma concentrations are often used to assess nutritional status and hepatic function. In people with systemic inflammation, synthesis of albumin is reduced, since the liver prioritizes acute-phase protein synthesis. Systemic inflammation is evident by the imbalance between proinflammatory and anti-inflammatory cytokines, causing high CRP blood levels(Alcorta et al., 2018). Decreased albumin levels are associated with an increased risk of complications and mortality, and a worse outcome in patients. Nevertheless, in acute process changes, it is not very sensitive as a nutritional marker due to its long half-life (20 days)(Garwe et al., 2016). Prealbumin, also known as transthyretin, has been routinely used in clinical practice which could efficiently reflect the nutritional status of patients. It is main synthesized by the liver and nowadays often preferred over albumin because of its shorter half-life that detects more rapid changes of the nutritional state. However, clinical biochemical findings have a significant impact on patient outcomes because they are considered more reliable in determining a correct diagnosis, similar risk classification, treatment, and prognosis.

Serum CRP is a well-established systemic inflammatory marker. Accumulating evidence suggests that in patients with gastric cancer elevated pre-operative CRP levels are significantly associated with a poor prognosis[30]. Moreover, a recent systematic review and meta-analysis of observational studies explored that sarcopenia appears to be associated with elevated serum inflammatory markers, especially higher levels of CRP(Bano et al., 2017). The investigating relationship between muscle strength with clinical, and hospital characteristics of 203 advanced cancer patients also presented that CRP levels significantly was different in categorizing patients with categorical muscle strength(Kilgour RD et al., 2013).

In the study, the determining factors for severe nutritional status, according to PG-SGA, were advanced age and low KPS. Advanced age is highly prone to malnutrition due to a combination of different factors include physiological changes that accompany advancing age such as decreased taste and smell, anorexia, decrease in gastric acid secretion which can limit the absorption of iron and vitamin B12(Abate et al., 2020), inaccessibility to get and prepare food due to functional decline that accompanies aging and reduced social contact, all of which can affect food intake. Likewise, a study of malnutrition in older adults with cancer which carried out by Lacau et al.(Lacau et al., 2018) reported that patients aged 70 years and above were more frequently malnourished than patients aged less than 70 years. In addition, as advanced cancer patients normally already have a high degree of fragility in relation to functional capacity, linked to the fact that they are probably with complications responsible for the demand for hospitalization, it is not surprising that we verified the presence of functionality limitation in most of the malnutrition patients (KPS<80).

Considering the high mortality rate among patients who start palliative care already demanding hospitalization and recognizing the need to better predict the occurrence of this type of outcome, we found that, presenting an advanced cancer with localization in the GI tract, PG-SGA ≥ 9, and nutritional symptoms (fatigue, weight loss) were predictive factors of this unfavorable outcome. Although most of the studies have investigated the relationship between survival and poor nutritional status in patients with particular histopathology, this study included all cancer patients without exclusion by histopathology. Thus, the effect of poor nutritional status on survival in all cancer patients, regardless of histopathology, was determined.

Malnutrition frequently coexists in advanced cancer patients. Such result might be due to that advanced cancer is associated with high levels of proinflammatory cytokines which cause anorexia and increase the susceptibility of malnutrition. Moreover, advanced stage is characterized by more severe symptoms and more adverse effects of treatment which interfere with food intake. This result is in harmony with a study carried out in USA by Klute et al. (2016) which reported that malnutrition is common in those with advanced cancer than in the early stages. Regarding our findings that relate the location of the tumor and the impact on the survival time, patients with GI cancer are known to have a shorter survival time than those with other tumor sites. In our study, GI cancer includes pancreas, liver & intrahepatic bile duct, stomach, colorectum, esophagus. According to cancer statistics 2022(Siegel et al., 2022), for all stages combined, the 5-year relative survival rates are lowest for cancers of the pancreas (11%), liver and esophagus (20%) and lung (22%).

Furthermore, we found that the PG-SGA score was associated with OS. Patients with PG-SGA scores of 0–8 had significantly longer mean survival. This finding was supported by other studies, which also found an association between nutritional status and clinical outcome. Souza et al(Souza et al., 2018) reported that nutritional status, which was assessed by PG-SGA, might be a determinant of prognosis in patients with advanced cancer in palliative care. There was a study showing their accuracy in predicting malnutrition and survival status in gynecological cancer patients(Laky et al., 2010), which is considered as the best standard questionnaire to assess the nutritional status in oncologic patients. Given these study results, we speculated that the PG-SGA score might exert more potent prognostic value.

The study findings revealed that nutrition impact symptoms (fatigue, weight loss) were statistically significant independent predictor for survival time. These symptoms might relate with metabolic problems that are induced by advanced cancer. Advanced stage is characterized by more severe symptoms and more adverse effects of treatment which interfere with food intake. Many patients with advanced cancer were consuming diets that would likely be insufficient to maintain weight, in addition, they have higher consumption of protein and fat, which could lead to weight loss. Most patients with advanced cancer experience symptoms throughout the disease trajectory, often with greater intensity as death approaches. Fatigue is highly prevalent, affecting three quarters of patients with advanced cancer, perhaps related to the proinflammatory state that plays a role in its pathogenesis[38]. Based on these results, the need for early symptom management and nutrition management is of paramount importance.

The study has some limitations that needs to be noted when interpreting results. First, in contained a small sample, which may have limited the inference power of statistical analyses. The study aimed to determine the rate of severe nutritional status among advanced cancer patients in palliative care and to evaluate the effect of severe nutritional status on survival time. The sample size caused some limitations for the second purpose while it was suitable for the first one. Moreover, it is a retrospective study design, a potential of selection bias and incomplete data collection may affect the study outcome. Further prospective stratification and planned randomized studies are warranted to assess whether the PG-SGA can predict the risk of poor clinical outcomes such as survival and quality of life in advanced cancer patients. Also, the patient population was selected from a single institution, which may also impinge on the data analysis.

In conclusion, nutritional status affects the prognosis of patients with advanced cancer patients in palliative care. For advanced cancer patients, nutritional deficiency is an important problem and it should be evaluated as an important prognostic marker.

Early detection of poor nutritional status with PG-SGA is significant to plan effective supportive care and anticancer treatments. Nutrition counseling and education from diagnosis to the end of the treatment may improve nutritional status and survival time in the patients. And PG-SGA can be used as an evaluation tool to determine nutritional status in the treatment and follow-up in advanced cancer patients.

Disclosure

The authors report no conflicts of interest in this work.

Conflict of Interest

The authors have no conflicts of interest to disclose. And this paper was not supported by the funding.

Statement of Authorship

Each person listed on this manuscript has participated in the study to a significant extent, and has adhered to ethical standards of research conduct.

Abate, T., Mengistu, B., Atnafu, A. & Derso, T. (2020). Malnutrition and its determinants among older adults people in Addis Ababa, Ethiopia. BMC Geriatrics, 20(1), 498.
Alcorta, M. D., Alvarez, P. C., Cabetas, R. N., Martin, M. A., Valero, M. & Candela, C. G. (2018). The importance of serum albumin determination method to classify patients based on nutritional status. Clin Nutr ESPEN, 25, 110–113.
Arends, J., Baracos, V., Bertz, H., Bozzetti, F., Calder, P. C., Deutz, N. E. P., Erickson, N., Laviano, A., Lisanti, M. P., Lobo, D. N., McMillan, D. C., Muscaritoli, M., Ockenga, J., Pirlich, M., Strasser, F., de van der Schueren, M., Van Gossum, A., Vaupel, P. & Weimann, A. (2017). ESPEN expert group recommendations for action against cancer-related malnutrition. Clinical nutrition (Edinburgh, Scotland), 36(5), 1187–1196.
Baba, H., Kuwabara, K., Ishiguro, T., Hatano, S., Matsuzawa, T., Fukuchi, M., Kumagai, Y., Ishibashi, K., Mochiki, E. & Ishida, H. (2013). C-reactive protein as a significant prognostic factor for stage IV gastric cancer patients. ANTICANCER RESEARCH, 33(12), 5591–5595.
Bano, G., Trevisan, C., Carraro, S., Solmi, M., Luchini, C., Stubbs, B., Manzato, E., Sergi, G. & Veronese, N. (2017). Inflammation and sarcopenia: A systematic review and meta -analysis. MATURITAS, 96, 10–15.
Barata, A. T., Santos, C., Cravo, M., Vinhas, M. D., Morais, C., Carolino, E., Mendes, L., Roldao, V. J. & Fonseca, J. (2017). Handgrip Dynamometry and Patient-Generated Subjective Global Assessment in Patients with Nonresectable Lung Cancer. NUTRITION AND CANCER-AN INTERNATIONAL JOURNAL, 69(1), 154–158.
Bullock, A. F., Greenley, S. L., McKenzie, G., Paton, L. W. & Johnson, M. J. (2020). Relationship between markers of malnutrition and clinical outcomes in older adults with cancer: systematic review, narrative synthesis and meta-analysis. EUROPEAN JOURNAL OF CLINICAL NUTRITION, 74(11), 1519–1535.
Cordeiro LAF, Silva TH, de Oliveira LC & Neto JFN (2020). Systemic Inflammation and Nutritional Status in Patients on Palliative Cancer: A Systematic Review of Observational Studies. Am J Hosp Palliat Care, 37(7), 565–571.
Datema, F. R., Ferrier, M. B. & Baatenburg, D. J. R. (2011). Impact of severe malnutrition on short-term mortality and overall survival in head and neck cancer. ORAL ONCOLOGY, 47(9), 910–914.
Garwe, T., Albrecht, R. M., Stoner, J. A., Mitchell, S. & Motghare, P. (2016). Hypoalbuminemia at admission is associated with increased incidence of in-hospital complications in geriatric trauma patients. AMERICAN JOURNAL OF SURGERY, 212(1), 109–115.
Gellrich, N. C., Handschel, J., Holtmann, H. & Kruskemper, G. (2015). Oral cancer malnutrition impacts weight and quality of life. Nutrients, 7(4), 2145–2160.
Gul, B., Metintas, S., Ak, G., Yilmaz, S. & Metintas, M. (2021). The relationship between nutritional status and prognosis in patients with locally advanced and advanced stage lung cancer. SUPPORTIVE CARE IN CANCER, 29(6), 3357–3365.
Henson, L. A., Maddocks, M., Evans, C., Davidson, M., Hicks, S. & Higginson, I. J. (2020). Palliative Care and the Management of Common Distressing Symptoms in Advanced Cancer: Pain, Breathlessness, Nausea and Vomiting, and Fatigue. JOURNAL OF CLINICAL ONCOLOGY, 38(9), 905–914.
Hui, D., Paiva, C. E., Del, F. E., Steer, C., Naberhuis, J., van de Wetering, M., Fernandez-Ortega, P., Morita, T., Suh, S. Y., Bruera, E. & Mori, M. (2019). Prognostication in advanced cancer: update and directions for future research. SUPPORTIVE CARE IN CANCER, 27(6), 1973–1984.
Jager-Wittenaar, H. & Ottery, F. D. (2017). Assessing nutritional status in cancer: role of the Patient-Generated Subjective Global Assessment. Curr Opin Clin Nutr Metab Care, 20(5), 322–329.
Khan AA, Klonizakis M, Shabaan A & Glynne-Jones R (2013). Association between pretreatment haemoglobin levels and morphometric characteristics of the tumour, response to neoadjuvant treatment and long-term outcomes in patients with locally advanced rectal cancers. Colorectal Disease, 15(10), 1232–1237.
Kilgour RD, Vigano A, Trutschnigg B, Lucar E, Borod M & Morais JA (2013). Handgrip strength predicts survival and is associated with markers of clinical and functional outcomes in advanced cancer patients. SUPPORTIVE CARE IN CANCER, 21(12), 3261–3270.
Lacau, S. G. J., Bouvard, E., Raynard, B., Goldwasser, F., Maget, B., Prevost, A., Seguy, D., Romano, O., Narciso, B., Couet, C., Balon, J. M., Vansteene, D., Salas, S., Grandval, P., Gyan, E. & Hebuterne, X. (2018). NutriCancer: A French observational multicentre cross-sectional study of malnutrition in elderly patients with cancer. Journal of Geriatric Oncology, 9(1), 74–80.
Laky, B., Janda, M., Kondalsamy-Chennakesavan, S., Cleghorn, G. & Obermair, A. (2010). Pretreatment malnutrition and quality of life - association with prolonged length of hospital stay among patients with gynecological cancer: a cohort study. BMC CANCER, 10, 232.
Maasberg, S., Knappe-Drzikova, B., Vonderbeck, D., Jann, H., Weylandt, K. H., Grieser, C., Pascher, A., Schefold, J. C., Pavel, M., Wiedenmann, B., Sturm, A. & Pape, U. F. (2017). Malnutrition Predicts Clinical Outcome in Patients with Neuroendocrine Neoplasia. NEUROENDOCRINOLOGY, 104(1), 11–25.
McGrane, J. M., Humes, D. J., Acheson, A. G., Minear, F., Wheeler, J. & Walter, C. J. (2017). Significance of Anemia in Outcomes After Neoadjuvant Chemoradiotherapy for Locally Advanced Rectal Cancer. Clin Colorectal Cancer, 16(4), 381–385.
National Comprehensive Cancer Network (2022). NCCN Clinical Practice Guidelines in Oncology Pallitive Care., Vol. 2022.
Pan, J., Wang, J., Wei, Y., Zhang, T., Zhang, S., Ye, D. & Zhu, Y. (2021). Combination of body mass index and albumin predicts the survival in metastatic castration-resistant prostate cancer patients treated with abiraterone: A post hoc analysis of two randomized trials. Cancer Med, 10(19), 6697–6704.
Pastore, C. A., Orlandi, S. P. & Gonzalez, M. C. (2014). The Inflammatory-Nutritional Index; assessing nutritional status and prognosis in gastrointestinal and lung cancer patients. Nutr Hosp, 29(3), 629–634.
Planas, M., Alvarez-Hernandez, J., Leon-Sanz, M., Celaya-Perez, S., Araujo, K. & Garcia, D. L. A. (2016). Prevalence of hospital malnutrition in cancer patients: a sub-analysis of the PREDyCES(R) study. SUPPORTIVE CARE IN CANCER, 24(1), 429–435.
Qiao, W., Leng, F., Liu, T., Wang, X., Wang, Y., Chen, D. & Wei, J. (2020). Prognostic Value of Prealbumin in Liver Cancer: A Systematic Review and Meta-Analysis. NUTRITION AND CANCER-AN INTERNATIONAL JOURNAL, 72(6), 909–916.
Ryan AM, Prado CM, Sullivan ES, Power DG & Daly LE (2019). Effects of weight loss and sarcopenia on response to chemotherapy, quality of life, and survival. NUTRITION, 67–68.
Santucci, C., Carioli, G., Bertuccio, P., Malvezzi, M., Pastorino, U., Boffetta, P., Negri, E., Bosetti, C. & La Vecchia, C. (2020). Progress in cancer mortality, incidence, and survival: a global overview. EUROPEAN JOURNAL OF CANCER PREVENTION, 29(5), 367–381.
Siegel, R. L., Miller, K. D., Fuchs, H. E. & Jemal, A. (2022). Cancer statistics, 2022. CA: a cancer journal for clinicians, 72(1), 7–33.
Silva, G., Wiegert, E., Calixto-Lima, L. & Oliveira, L. C. (2020). Clinical utility of the modified Glasgow Prognostic Score to classify cachexia in patients with advanced cancer in palliative care. CLINICAL NUTRITION, 39(5), 1587–1592.
Sjoquist, K. M., Renfro, L. A., Simes, R. J., Tebbutt, N. C., Clarke, S., Seymour, M. T., Adams, R., Maughan, T. S., Saltz, L., Goldberg, R. M., Schmoll, H. J., Van Cutsem, E., Douillard, J. Y., Hoff, P. M., Hecht, J. R., Tournigand, C., Punt, C., Koopman, M., Hurwitz, H., Heinemann, V., Falcone, A., Porschen, R., Fuchs, C., Diaz-Rubio, E., Aranda, E., Bokemeyer, C., Souglakos, I., Kabbinavar, F. F., Chibaudel, B., Meyers, J. P., Sargent, D. J., de Gramont, A. & Zalcberg, J. R. (2018). Personalizing Survival Predictions in Advanced Colorectal Cancer: The ARCAD Nomogram Project. J Natl Cancer Inst, 110(6), 638–648.
Sonneborn-Papakostopoulos, M., Dubois, C., Mathies, V., Hess, M., Erickson, N., Ernst, T. & Huebner, J. (2021). Quality of life, symptoms and dietary habits in oncology outpatients with malnutrition: A cross-sectional study. MEDICAL ONCOLOGY, 38(2), 20.
Souza, C. M., Wiegert, E., Calixto-Lima, L. & Oliveira, L. C. (2018). Relationship of nutritional status and inflammation with survival in patients with advanced cancer in palliative care. NUTRITION, 51–52, 98–103.
Vigano, A. L., di Tomasso, J., Kilgour, R. D., Trutschnigg, B., Lucar, E., Morais, J. A. & Borod, M. (2014). The abridged patient-generated subjective global assessment is a useful tool for early detection and characterization of cancer cachexia. Journal of the Academy of Nutrition and Dietetics, 114(7), 1088–1098.
Wang, L. & Shao, Z. H. (2018). Relationship between anemia and clinical features and prognosis of advanced lung cancer patients. Zhonghua Zhong Liu Za Zhi, 40(7), 512–516.
Xia, C., Dong, X., Li, H., Cao, M., Sun, D., He, S., Yang, F., Yan, X., Zhang, S., Li, N. & Chen, W. (2022). Cancer statistics in China and United States, 2022: profiles, trends, and determinants. CHINESE MEDICAL JOURNAL, 135(5), 584–590.
Yan, X., Zhang, S., Jia, J., Yang, J., Song, Y. & Duan, H. (2021). Exploring the malnutrition status and impact of total parenteral nutrition on the outcome of patients with advanced stage ovarian cancer. BMC CANCER, 21(1), 799.
Zhang, Q., Li, X. R., Zhang, X., Ding, J. S., Liu, T., Qian, L., Song, M. M., Song, C. H., Barazzoni, R., Tang, M., Wang, K. H., Xu, H. X. & Shi, H. P. (2021). PG-SGA SF in nutrition assessment and survival prediction for elderly patients with cancer. BMC Geriatrics, 21(1), 687.

No competing interests reported.

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The relationship between nutritional status and prognosis in advanced cancer patients in palliative care: a retrospective study

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