Globally, cancer case and complication is on increasing. Moreover, malnutrition is becoming one of the most common complications of patients with cancer due to systemic effect of the disease and side effects of cancer therapy including oral mucositis, constipation, impaired sense of taste and tissue damage. Hence; early screening of malnutrition is a corner stone in cancer management. SGA as a gold standard in routine service, but the implementation is rare. Therefore, this study aims to evaluate serum albumin, TP and Hgb derangements correlated with SGA tool as an alternative diagnostic modality for early and better diagnosis of malnutrition. In the current study, a total of 176 adult patients with cancer were grouped into malnourished and well-nourished based on SGA nutritional assessment tool validated and employed in patients with cancer (15, 20, 51).
In the current study, from 176 adult patients with cancer, more than two-thirds (69.3%) of the patients were female and 52.3% of them were between 35–54 years of age (Table 1). This finding was in harmony with study conducted at TASH, Addis Ababa. This high female adult cancer patient finding might be explained by increased on cancer screening and frequent health facility visits during child birth and pregnancy. Moreover, female can develop cancer related to their reproductive organs. Furthermore, working age group being affected consequently might have influence on economy of the country. From the study participants, stages of cancer were distributed as stage I 18(10.2%), stage II 33(18.8%), stage III 52 (29.5%) and stage IV 73(41.5%) (Table 1). The high percentage of an advanced stage IV finding was consistent with study done in Santamaria, Brazil stage IV (43%) (30). This high percentage of advanced stage (41.5%) of cancer may be explained due to low awareness on clinical manifestations of cancer, and use of traditional remedies (53, 54).
Our study found that about 49.4% was hypoalbuminemic. The result of hypoalbuminemia in patients with cancer might be due to cancer patient, pro-inflammatory cytokines (TNF-α, IL-2, and IL-6) induced positive acute phase reactant synthesis compete for nutrient in liver leads to decreases in serum albumin production (55). Another explanation could be highly proliferating cancer cells increased uptake of serum albumin through induce Albumin Binding Proteins (ABP) (56). But hypoalbuminemia prevalence in this study was high as compared to findings in Ivory coast(13.5%) (57), Palestine(14%) (6) and Malaysia(33%) (13). The possible justification for discrepancy with study done Ivory coast (53 sample), Palestine (100 sample) and Malaysia (100 sample) might be due to relatively small sample size. Similarly, in the current study magnitude of hypoalbuminemia (49.4%) was higher than study done in Zimbabwe (28.6%). This could be due to relatively small sample size (63 sample), study population difference (on radiotherapy), and limited to few types of cancer (breast, cervical and prostate) (58). In contrary to this, in the current study, lower prevalence of hypoalbuminemia than the study done in University of Pelotas, Brazil (68.9%) with relatively small sample size (74 sample size) (59).
In this study, there was statstically significant negative correlation(r=-0.491, P < 0.001) between serum albumin and SGA score level (Table 4). The finding is in harmony with the studies conducted at Nigeria (29) and Santamaria, Brazil (30) and Greek (42) reported a significantly low level of serum albumin in patients with cancer with malnutrition. Even though there is no evidence in contrary to the current finding in regards of all cancer types; there was evidence with restricted types of cancer. The study conducted in China reported no significant correlation between serum albumin and malnutrition in patients with cancer. This discrepancy might be due to study population limited with early stage and single type of cancer(esophageal cancer) (60).
In the current study, mean level of serum albumin was low in patients with malnutrition (3.03 ± 0.58g/dl) as compared to well-nourished (3.71 ± 0.58 g/dl) adult patients with cancer, and the difference was statistically significant (Table 3). The finding of this study is consistent with study done in Santamaria, Brazil (30). The possible explanation could be in cancer related malnutrition, nutrient deprivation and inflammation, downregulates serum albumin gene expression leading to inhibition of synthesis (24). Furthermore, possible explanation could be since plasma antioxidant, serum albumin, scavenges high free radical level of oxidative stress in cancer related malnutrition leading to serum albumin depletion (24, 61). Another possible justification could be, in malnutrition associated glucose metabolic alteration leads to insulin resistance (62), which inhibits serum albumin gene expression. A study done in China which opposes the current finding reported no significant mean difference of serum albumin level between malnourished and well-nourished patients (60). The difference could be due to their study population restriction to chemo radiotherapy treated esophageal cancer before and after radiation therapy.
In the current finding, malnourished were 4 times more likely to have hypoalbuminemia than well-nourished (Table 5). This study is supported with meta-analysis of hypoalbuminemia as nutritional marker in patients with cancer (38). The finding also supported with the study conducted in Bari, Italy verified association of hypoalbuminemia with malnutrition among restricted study population of colorectal patients with cancer (39). The possible justification for this could be due to cancer related malnutrition (CRM) associated inflammatory mediators TNF-α, IL-2,and IL-6 inhibits serum albumin gene expression, enhance vascular permeability of plasma serum albumin clearance, and degradation of serum albumin to generate amino acid for tissue protein synthesis and low protein diet decreases serum albumin level (24).
This study finding shows that Being GI patients with cancer were 3 times more likely to have hypoalbuminemia than breast patients with cancer (Table 5). The finding is supported with study done in Iran serum albumin level is significantly lower in GI patients with cancer than non-GI patients with cancer (63). Also, advanced stage IV adult patients with cancer (64.4%) had 5 times more likely develop hypoalbuminemia than patients on stage I (Table 5). The finding of this study supported with study done in Malaysia(47.7%) reported stage IV cancer was associated with hypo albuminuria (13). This is could be due to advanced stage cancer cells increased uptake of serum albumin (56). But our finding is contrary with study done in Ivory coast, which verify no association between serum albumin level and stage of cancer (57). This discrepancy with Ivory Coast study may be due to small number of metastatic stage of cancer (12 patients), relatively small sample size (53 sample).
In the current study magnitude of hypoproteinemia was 34.1%. This hypoproteinemia may be due to poor nutritional status, increases degradation of protein for tissue protein synthesis and its antioxidant role. The finding of our study is very close to study done in Algeria (31.1%) (64) with colorectal cancer restricted study participant. In contrary, the study finding magnitude of hypoproteinemia is higher than study done in Zimbabwe (4.7%) (58). This is due to relatively small sample size (63 samples), study population limitation (on radiotherapy treatment only), and restricted to type of cancer (breast cancer, cervical cancer and prostate cancer).
A statistically significant negative weak correlation (r=-270, p < 0.001) was also observed between TP level and SGA score (Table 4). This is consistent with study done in Greek among oncology patients (42). In the present study, mean level of TP had statistically significant difference between malnourished (6.52 ± 0.94 g/dl) and well-nourished (7.01 ± 1.01 g/dl) adult patients with cancer (Table 3). This study finding is in line with study done in Greek among oncology patients (42). In this study, malnutrition was also found significantly associated with hypoproteinemia. Participants who are malnourished (44.4%) were 3 times more likely to have hypoproteinemia than well-nourished (17.6%) adult patients with cancer. It could be due to nutrient deprivation alter protein hemostasis by inhibiting protein synthesis (34).
This study finding showed that adult patients with cancer of age > 64 years was 6 times more likely to have hypoproteinemia than 18–36 years patients with cancer (Table 5). The finding of this study supported with a study conducted among adult patients with cancer in Athens, Greece indicated that age was the predictors of post-operative hypoproteinemia (40). The possible reason for hypoproteinemia could be, as age progresses, inflammation increases and hepatocyte compromised in number, volume and functions are results in decreased protein synthesis. In contrary, the study done in Zimbabwe shows that no significant difference of hypoproteinemia in different age group (58). This discrepancy may be due to difference in patient’s age cut-off point to classify age group and previous study was concerned on few cancer types. Patients with GI cancer were 3 times more likely develop hypoproteinemia than breast patients with cancer (Table 5). The possible explanation could be, in GI cancer increase in mucosal permeability caused by inflammation, leading to excessive leakage of serum protein to the gut and reduce its reabsorption leads to hypoproteinemia (65).
In the current study, the magnitude of low Hgb level in patients with cancer was 50%. It could be related to cancer treatment or disease. This magnitude is higher when compared to finding in Palestine (24%) (6), Addis Ababa, Ethiopia (23%) (66), and Saudi Arabia (44.1%) (67). In contrary to it is very lower as compared to finding in Tanzania(86%) (68), this inconsistencies could be due to study population restricted to radiotherapy patients, and include blood transfused patients (21.3%) in previous study. A significant inverse correlation (r=-0.451, p < 0.001) was also observed between Hgb level and SGA score (Table 4). The finding is supported with study conducted in Jordan among colorectal patients with cancer with study population restriction (69).
This study also found that the mean level of Hgb was significantly decreased in malnourished patients (13.26 ± 1.51g/dl) as compared to well-nourished (11.18 ± 2.16g/dl) adult patients with cancer (Table 3). The possible explanation could be in cancer related malnutrition, ROS and IL-6, induces hepcidin, which degrade ferroportin and halt the uptake of iron from small intestine and macrophage leading to unavailability of iron for heme synthesis (36). Another potential explanation for this might be due to disruption of glucose metabolism contributes to low Hgb levels. This is because the Krebs cycle affects the availability of substrate for heme synthesis (37). Furthermore, this finding is in parallel with study done in Italy (39). In contrary to the current finding, study done in Greek revealed that there is statically insignificant differences in mean level of Hgb between malnourished and well-nourished according to SGA (42). The discrepancy could be due to relatively small sample size (88 patients).
Participants who are malnourished were 3.8 times more likely to have low Hgb level than well-nourished adult patients with cancer (Table 5). This is supported with a study done in Italy (39). This may be due to in malnourished patients with cancer tumor cell-mediated cytokines such as IL-1, Il-6, and (TNF-α) cause hemolysis, lowering Hgb levels (37). In the current study advanced stage IV patients with cancer were 3.9 times more likely to have low Hgb than other stage I patients with cancer (Table 5). This finding is supported with study done in Cagliari, Italy which elucidate patients with advanced stage of cancer had low Hgb level (41). The possible explanation could be as stage of cancer more advanced; tumor cells number and nutrient requirement increased which leads to low Hgb level. Furthermore, in advanced cancer, the increased new blood vessels formation requires blood cell may decreases Hgb level (70). Similarly, the current study finding is supported with study done in Addis Ababa being stage IV patients with cancer are risky than stage I (53, 66).
Strength and Limitations
Due to the study was carried on a single cancer center; the finding might not be national wise representative. Another limitation of this study didn’t assess biochemical markers serum prealbumin due to lack of reagent and financial issue. In addition, 2/3 of the participants were female which is most likely not representative of the population of patients with cancer. Moreover, due to cross-sectional nature of the study, associations can be identified although correlations are not necessarily derived.