Association of Patient-Generated Subjective Global Assessment score with surgical outcomes in women with gynecologic cancer

doi:10.21203/rs.3.rs-4144003/v1

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Association of Patient-Generated Subjective Global Assessment score with surgical outcomes in women with gynecologic cancer

https://doi.org/10.21203/rs.3.rs-4144003/v1

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Objective: To evaluate the association between nutritional status assessed by the Patient-Generated Subjective Global Assessment (PG-SGA) score and surgical complications in patients diagnosed with gynecologic cancer undergoing surgical treatment.

Methods: This was a retrospective study comprising women with gynecologic cancer scheduled for surgical treatment. Nutritional diagnosis was obtained using the PG-SGA, and postoperative outcomes were analyzed, classified, and associated with patients’ nutritional status. For statistical analyses, patients were divided into 2 groups according to PG-SGA score classification. Associations between categorical variables were assessed using the chi-square (χ²) test. Differences in median values of continuous variables were compared using the Mann-Whitney U test. Logistic regression analyses were conducted to determine the likelihood of postoperative complications occurring in patients with higher PG-SGA scores (≥ 4).

Results: The sample consisted of 370 women, with endometrial cancer being the most common cancer. According to PG-SGA, patients with higher scores had longer hospital stays, were more likely to undergo noncurative surgeries, remained in postoperative fasting for a longer duration, and experienced greater postoperative mortality.

Conclusion: Our findings support the use of the PG-SGA as a useful tool for assessing the nutritional status of patients with gynecologic tumors and enabling early intervention in patients at nutritional risk or who are malnourished to optimize nutritional status before surgical intervention and reduce the likelihood of postoperative complications.

subjective global assessment

nutritional status

perioperative outcomes

gynecologic cancer

The incidence and mortality of cancer are rapidly increasing worldwide, as reflected by population aging, demographic growth, and increased exposure to major cancer risk factors [1]. Various factors influence its development, including individual inherent factors (age, sex, genetics, etc.), environmental factors (viruses, ultraviolet radiation, pollutants, etc.), dietary factors (energy intake, nutrients, food bioactives, alcohol, etc.), and lifestyle factors (physical activity, smoking, etc.) [2].

According to the World Health Organization (WHO), by 2040, the number of new cancer cases diagnosed is expected to be approximately 50% greater than that in 2020 [3]. According to the National Cancer Institute (INCA), it is estimated that for each year of the 2023–2025 triennium, there will be about 704.000 new cases in Brazil, of which 24.850 will be uterine in origin and 7.310 will be ovarian [4].

Cancer treatment can include surgery, chemotherapy, and or radiotherapy. For most gynecologic cancers, surgery is the primary treatment option [5]. The surgical approach depends on tumor size and which organs are affected; some surgeries involve only lesion removal, but in some cases, total removal of the uterus and its ligaments, as well as organs such as the bladder and rectum, may be necessary. These are typically large, complex surgeries that can lead to complications.

Currently, studies are being conducted to support improvements in of perioperative care based on scientific evidence. In this context, the Enhanced Recovery After Surgery (ERAS) Project provides evidence to support standardization in these care processes, aiming primarily to reduce hospital stay and perioperative morbidity without increasing readmission rates [6]. The essential elements of the protocol include reducing preoperative fasting periods, early postoperative refeeding, perioperative nutritional therapy, antibiotic prophylaxis, abolishing bowel preparation in elective colorectal surgeries, reducing intravenous fluid use perioperatively, restricting nasogastric tube and drain use, and administering perioperative analgesia [7].

According to ESPEN [8], there is clear evidence that malnutrition is associated with worse outcomes in surgical patients, and surgical stress and trauma induce catabolism. The nutritional status of cancer patients can be assessed by various methods. Laky et al. [9] showed that body mass index (BMI), body weight and percentage of weight loss alone cannot be used to detect malnutrition in patients with gynecologic cancer, especially when pelvic masses and/or ascites are present [10].

The Patient-Generated Subjective Global Assessment (PG-SGA) form can be used, which is an easy-to-administer, low-cost, non-invasive nutritional screening instrument, internationally validated for oncology patients [11], considered a reference due to its high sensitivity and specificity [12; 13]. This tool allows the identification of individuals at risk of malnutrition or who are already malnourished, facilitating early and appropriate intervention, and is more appropriate than objective parameters, as it assesses nutritional status based on weight history, food intake, gastrointestinal symptoms, functional capacity, metabolic stress, and physical examination [14].

Several studies have been published using the PG-SGA and cancer; however, none have specifically evaluated the nutritional status through the PG-SGA of patients with gynecologic tumors and their surgical outcomes. Thus, the present study aimed to evaluate the association between nutritional status assessed by the PG-SGA score and surgical complications in patients diagnosed with gynecologic cancer undergoing surgical treatment.

Study Design

This was a retrospective observational study, in wich adult female patients over 20 years of age with a diagnosis of gynecologic cancer, who were enrolled at INCA in the years 2018 and 2019 with proposed surgical treatment, were included. Patients who did not undergo surgery, those with a diagnosis of benign or non-gynecologic tumors, and those who did not have a PG-SGA at the time of admission were excluded.

The study protocol was approved by the ethics committee of INCA, under number 27285019.8.0000.5274.

Data collection

Patient follow-up was conducted at the screening clinic, nutrition outpatient clinic, hospital admission for surgical procedure, and up to 30 days after hospital discharge. The data were obtained through review of physical and electronic medical records, entered into a standardized data collection form, and completed by a trained nutritionist. Sociodemographic data of the patients, history of smoking, alcohol consumption, past medical history – of diabetes mellitus (DM) and systemic arterial hypertension (SAH) - previous oncological treatments (chemotherapy, radiotherapy and surgery), and laboratory tests (blood glucose, hemoglobin and serum albumin) were collected. Information about the surgery performed, whether preoperative fasting abbreviation, occurred the use of oral immunomodulatory nutritional therapy, the duration of anesthetic induction and the end of surgery, intraoperative blood loss, and surgical and digestive complications such as nausea and vomiting, both in the immediate postoperative period, considered the period between 24 hours and 7 days after surgery, and in the late postoperative period, considered the period after 7 days of surgery, were also collected. Information regarding the day and time of the last meal and the resumption of an oral diet, were also collected to assess pre-and postoperative fasting times. Prolonged fasting was considered when feeding was not resumed by the third postoperative day, and the length of hospital stay was also recorded. The tumor location, histological subtype and degree of differentiation were confirmed through histopathological reports.

Data regarding the therapeutic itineraries of the patients, such as the dates of the first clinical treatment, hospital admission for surgery and hospital discharge, were also collected.

Nutritional Status

Anthropometric evaluation was performed upon hospital admission for surgery by measuring body weight and height, calculating body mass index (BMI) and subsequently classifying nutritional status according to the criteria of the WHO [15] for adult patients (< 60 years) and the Pan American Health Organization [16] for elderly patients (≥ 60 years).

For subjective nutritional assessment, the PG-SGA tool in the Brazilian version translated and validated by Gonzalez et al. [17] was used. This instrument allows the classification of patients' nutritional status into categories A (well-nourished or anabolic), B (moderate malnutrition or suspicion), or C (severely malnourished) and provides a score and recommendation for nutritional intervention. The sum of scores from these variables is used to define specific nutritional interventions, with a score between 0 and 1 indicating no need for intervention at that time, and reassessment should be routine during treatment; between 2 and 3, patients should receive counseling from a nutritionist, nurse, or other healthcare professional, with pharmacological intervention according to symptoms and laboratory tests; between 4 and 8, there is a need for intervention by a nutritionist, along with a nurse or doctor as indicated by the symptom survey; and ≥ 9 indicates an urgent need for better symptom management and/or nutritional intervention. The PG-SGA was performed at two time points: during screening and upon hospital admission.

The study participants underwent outpatient nutrition consultation, during which nutritional screening was performed, and whether there was a need for oral nutritional therapy with an immunomodulatory supplement was assesse. Patients who underwent major surgeries, and who were diagnosed with nutritional risk or malnutrition according to criteria established by the Nutrition and Dietetics Department, were recommended receive immunonutrition.

Postoperative Complications

Postoperative complications were considered within 30 days after surgery. They were classified as infectious (sepsis, pneumonia, bacteremia, urinary tract infection, or abdominal wall infection) and noninfectious (abdominal wall dehiscence, renal failure, respiratory failure, fistula and reoperation). Readmission and death within 30 days after surgery were also considered.

To classify surgical complications, the Clavien-Dindo classification [18], which grades and defines complications, was used. The classification ranges from I to V, where grade I is defined as any deviation from the ideal postoperative course without the need for pharmacological treatment or surgical, endoscopic or radiological interventions, and grade V is defined as patient death.

Statistical analysis

The collected data were recorded in Excel spreadsheets and analyzed using the Statistical Package for the Social Sciences (SPSS), version 22.

Adherence to the normal curve was tested using the Shapiro-Wilk test. A nonnormal distribution was identified for all variables. In the sample description, categorical variables are expressed as absolute values and percentages, and continuous variables expressed as median and interquartile ranges. For statistical analyses, patients were divided into 2 groups according to the PG-SGA score classification: group 1, with scores ranging from 0 to 3, and group 2, with scores ≥ 4. Associations between categorical variables were calculated using the chi-square test (χ²). To compare the differences between the medians of continuous variables, the Mann-Whitney U test was used. Logistic regression analyses were performed on variables with biological plausibility for association and p ≤ 0.2 to determine the likelihood of postoperative complications occurring in patients with higher scores (≥ 4). The PG-SGA score was the dependent variable, and was analyzed dichotomously. Potential confounding variables were included in the multivariate analysis. The analysis results are reported as p-values and Odds Ratios with 95% confidence intervals. Statistical significance was considered when the p-value was < 0.05.

The study sample initially comprised 682 eligible patients, but after the exclusion criteria were applied (179 did not undergo surgery, 34 were diagnosed with benign tumors, 9 had nongynecologic diagnoses, 27 did not have PG-SGA at the time of admission, 37 died before surgery and 26 discontinued treatment), the final sample consisted of 370 patients. There was a greater prevalence of elderly women (median age of 60 years), nonwhite individuals (61.1%), the majority of whom never smoked (64.2%) or drank alcohol (75.9%), and the most prevalent comorbidity was SAH (54.9%). The median BMI of the patients indicated that the majority were overweight. The median values of laboratory tests (hemoglobin, glucose and albumin) were within the reference ranges. Most patients had not undergone any prior treatment (Table 1).

Table 1

General characteristics of the studied population (n = 370).
Characteristics	n (%)
Age, years (median and IQR)	60 (49–66)
Race (%)
White	143 (38.8)
Brown	185 (50.3)
Black	40 (10.9)
Smoking (%)
Never smoked	237 (64.2)
Former smoker	99 (26.8)
Active smoker	31 (8.5)
Passive smoker	2 (0.5)
Alcohol consumption (%)
Never drank	281 (75.9)
Social drinker	88 (23.8)
Daily drinker	1 (0.3)
Comorbidities (%)
SAH	203 (54.9)
DM	82 (22.2)
Hemoglobin, g/dl (median and IQR)	13 (11–13)
Glucose, mg/dl (median and IQR)	99 (90–115)
Albumin, g/dl (median and IQR)	4 (4–4)
Previous chemotherapy (%)	1 (0.3)
Previous radiotherapy (%)	1 (0.3)
Previous surgery (%)	135 (36.5)
Neoadjuvant chemotherapy (%)	11 (3.0)

Legend: IQR: interquartile range; BMI: body mass index; kg: kilograms; m²: square meter; g: gram; dl: deciliter.

According to the tumor location, endometrial cancer was the most common, adenocarcinoma was the most common histological type, the most frequent histological subtype was endometrioid, and according to the degree of differentiation, 14.1% of tumors were classified as grade I, 22.7% as grade II, 28.3% as grade III, and 34.9% had no information. The most commonly performed surgery was total abdominal hysterectomy. In addition to the main surgery, 79.4% of patients also underwent salpingo-oophorectomy, 42.7% underwent lymphadenectomy, and only 1.1% underwent intestinal resection. Regarding the radicality of surgery, 81.4% of surgeries were considered R0 (radical surgery without evidence of residual disease), 1.1% were considered R1 (palliative surgery with evidence of microscopic residual disease), and 17.5% were considered R2 (palliative surgery with evidence of macroscopic residual disease) (Fig. 1).

Regarding the nutritional diagnosis obtained through the PG-SGA, an improvement in the nutritional status of the patients was observed at the time of admission compared to the time of screening, both by stage classification and by classification score. According to stage classifications A, B and C, the percentages were similar at both time points, with the majority of patients classified as stage A. Most patients who were indicated to use immunonutrition were classified into group B and C and group 2 (Table 2).

Table 2

Classification of the nutritional status of the studied population through the PG-SGA at the time of screening and hospital admission and indications for immunonutrition.
	Screening			Hospital admission
Stage classification	n (%)	Immunonutrition n (%)	p-value	n (%)	Immunonutrition n (%)	p-value
A	218 (66)	32 (9.7)	< 0.001	253 (68)	49 (13)	< 0.001
B and C	112 (34)	63 (19)	< 0.001	117 (32)	58 (16)	< 0.001
Score classification
Group 1	139 (43)	20 (6)	< 0.001	218 (59)	45 (12)	< 0.001
Group 2	187 (57)	74 (23)	< 0.001	152 (41)	62 (17)	< 0.001

Legend: Classification A: well-nourished or anabolic; B: moderate malnutrition or suspicion; C: severely malnourished. Group 1: score from 0 to 3; group 2: score ≥ 4.

The results comparing the two groups divided according to the PG-SGA score in relation to perioperative outcomes showed that patients in group 1 had a greater indication for fasting abbreviation and spent less time fasting than did patients in group 2. Gastrointestinal symptoms of nausea and vomiting both in the immediate and late periods, and surgical complications were similar between the groups and did not show statistical significance. However, patients in group 2 had more complications and more severe complications according to the Clavien-Dindo classification [18], longer hospital stays, and higher mortality rates, were more frequently subjected to exploratory laparotomy with biopsy, had a greater occurrence of palliative surgeries with evidence of macroscopic disease (R2 surgery) and patients in group 1 were more frequently subjected to lymphadenectomy and salpingo-oophorectomy. Regarding the site of surgery, endometrial cancer was more common in patients in group 1, and ovarian cancer was more common in patients in group 2 (Table 3).

Table 3

– Association between groups separated by the PG-SGA score of the studied population and their perioperative outcomes.
Variables (n)	Group 1	Group 2	p-value	Variables (n)	Group 1	Group 2	p-value	Variables (n)	Group 1	Group 2	p-value
Fasting abbreviation			0.001	Surgical site infection	7	4	0.703	Postop death	3	17	< 0.001
No	115	92		Extrasurgical site infection			0.174	Surgery performed			< 0.001
Yes	83	32		None	211	143		TAH I	145	91
Without medical deliberation	20	26		Pelvic collection	3	2		TAH II	26	9
Start of oral diet			0.281	Pneumonia	1	5		TAH III	1	0
Immediate postop	83	44		Bacteremia	0	1		TVH	2	2
First day postop	128	97		UTI	3	1		LE with BPO	10	35
Second day postop	4	5		Paralytic ileus	5	4	0.618	Vulvectomy	7	2
Third day postop	1	2		Evisceration	3	1	0.511	Others*	15	6
Reason for prolonged fasting			0.152	Abdominal wall dehiscence	5	3	0.756	Lymphadenectomy	104	54	0.020
No prolonged fasting	212	142		Ureterovaginal fistula	2	3	0.228	SOE and SOD	181	112	0.023
Nausea and vomiting	1	1		Renal failure	1	3	0.166	Blood loss			0.478
NGT in siphoning	0	4		Respiratory failure	2	3	0.387	< 500 ml	215	145
Surgery/surgeon protocol	2	1		Clavien-Dindo classification			0.035	500–1000 ml	3	2
Abdominal distension	1	0		No complication	187	122		> 1000 ml	0	1
Preop fasting time			0.023	Grade I	6	4		Residual surgery			< 0.001
Less than the median	126	67		Grade II	14	15		R0	199	99
Greater than the median	91	79		Grade IIIA	2	0		R1	1	3
Postop fasting time			0.005	Grade IIIB	7	1		R2	16	48
Less than the median	120	60		Grade IVA	1	3		Surgery site			0.001
Greater than the median	93	85		Grade IVB	1	4		Endometrium	113	59
Immediate postop nausea	47	36	0.664	Grade V	0	3		Ovary	38	54
Immediate postop vomiting	33	27	0.525	Lenght of hospital stay			< 0.001	Cervix	41	19
Late postop nausea	43	39	0.192	Less than the median	66	70		Vulva/vagina	6	3
Late postop vomiting	27	29	0.079	Greater than the median	150	69
Surgical complication	30	31	0.091	Readmission	21	16	0.762

Legend: postop: postoperative; NGT: nasogastric tube; preop: preoperative; UTI: urinary tract infection; TAH I: total abdominal hysterectomy type I; TAH II: total abdominal hysterectomy type II; TAH III: total abdominal hysterectomy type III; TVH: total vaginal hysterectomy; LE: exploratory laparotomy; BPO: biopsy; SOE: left salpingo-oophorectomy; SOD: right salpingo-oophorectomy; R0: radical surgery without evidence of residual disease; R1: palliative surgery with evidence of microscopic residual disease; R2: palliative surgery with evidence of macroscopic residual disease. Others*: surgical complementation and trachelectomy.

There was a significant difference between the medians of the groups according to the PG-SGA score in terms of the number of days between the day of surgery and admission (p < 0.001), preoperative fasting time (p < 0.001), postoperative fasting time (p = 0.002) and length of hospital stay (p < 0.001) (Fig. 2).

The multivariate logistic regression model demonstrated that patients with higher PG-SGA scores (≥ 4) were associated with 4 fold greater odds of longer hospital stays, nearly 4 fold greater odds of longer postoperative fasting times, and 5 fold greater odds of R1 and R2 surgeries than R0 surgeries were (Table 4).

Table 4

Logistic regression analysis of groups separated by PG-SGA score with surgical outcomes of the studied population (n = 370).
Variables	Univariate		Multivariate
	OR (95% CI)	p-value	OR (95% CI) Model 1	p-value	OR (95% CI) Model 2	p-value
Length of hospital stay (> median)	2.31 (1.48; 3.58)	< 0.001	2.20 (1.39; 3.50)	0.001	4.17 (1.14; 15.32)	0.031
Preoperative fasting time (> median)	1.63 (1.07; 2.49)	0.023	1.47 (0.94; 2.28)	0.090	2.11 (0.66; 6.68)	0.204
Posoperative fasting time (> median)	1.83 (1.19; 2.80)	0.006	1.87 (1.19; 2.92)	0.006	3.79 (1.10; 13.04)	0.035
Late nausea (yes)	1.39 (0.85; 2.28)	0.193	1.48 (0.88; 2.49)	0.136	2.04 (0.37; 11.21)	0.410
Late vomiting (yes)	1.66 (0.94; 2.95)	0.081	1.55 (0.85; 2.83)	0.150	4.69 (0.45; 48.94)	0.196
Lymphadenectomy (yes)	0.60 (0.39; 0.92)	0.020	0.68 (0.43; 1.05)	0.083	0.46 (0.12; 1.74)	0.252
Residual surgery (R1 and R2)	6.03 (3.26; 11.15)	< 0.001	6.85 (3.48; 13.52)	< 0.001	5.20 (1.19; 22.76)	0.029
Surgical complication (yes)	1.61 (0.92; 2.79)	0.092	1.41 (0.78; 2.54)	0.253	0.11 (0.14; 0.89)	0.039
Albumin (< 3.5 g/dl)	9.60 (2.69; 34.24)	< 0.001	10.04 (2,60; 38,77)	0.001	6.87 (0.94; 50.26)	0.058
Postoperative (yes)	8.89 (2.55; 30.94)	0.001	7.46 (2.08; 26.70)	0.002	-	-

Legend: R1: palliative surgery with evidence of microscopic residual disease; R2: palliative surgery with evidence of macroscopic residual disease.

Model 1: adjusted for age, smoking, DM, SAH, prior surgery and neoadjuvant chemotherapy after roundtable discussion.

Model 2: adjusted for age, smoking, DM, SAH, prior surgery, neoadjuvant chemotherapy after roundtable discussion, length of hospital stay, preoperative and postoperative fasting time, late nausea, late vomiting, lymphadenectomy, residual surgery, surgical complication and the albumin concentration.

Length of hospital stay: median = 4 days.

Preoperative fasting time: median = 765 minutes.

Postoperative fasting time: median = 1015 minutes.

The present study demonstrated that a worse preoperative nutritional status had a negative impact on surgical outcomes. Patients with higher PG-SGA scores (group 2) were associated with longer hospital stays, more complications, more severe complications and greater postoperative mortality. These findings are consistent with the study by Soloff et al. [19], which revealed the impact of malnutrition on postoperative outcomes in patients undergoing laparoscopic hysterectomy for benign conditions and revealed that patients with any type of malnutrition had significantly greater rates of developing any postoperative complication, with wound complications being the most common.

Laky et al. [20] reported that a prolonged hospital stay was associated with low levels of albumin, serum hemoglobin and with malnutrition. In our study, patients classified with any degree of malnutrition were associated with 4.1 times greater odds of experiencing longer hospital stays. This finding suggests that even a slight alteration in nutritional status can result in a longer hospital stay.

Many studies reinforce the importance of albumin levels, showing that poor preoperative nutritional status is associated with an increased incidence of complications [21; 22]. In the study by Lyell et al. [21], patients diagnosed with colorectal, gynecologic or urologic cancer who underwent pelvic exenteration and had preoperative albumin levels lower than 3.5 g/dl were associated with an increased incidence of postoperative complications (85.9% vs. 72.3%, p = 0.034). Bogani et al. [22] reported that albumin levels lower than 3.5 g/dl (OR: 16.2 [95% CI, 2.85–92.8]; p = 0.002) were associated with 90-day morbidity and low albumin levels were independently correlated with readmission (p = 0.011). According to the multivariate analysis in our study, patients with low albumin adjusted for age, smoking, DM, SAH, prior surgery and neoadjuvant chemotherapy after roundtable discussion (OR: 10.04 [2.60-38.77]; p = 0.001) had 10 times greater odds of being in the group with higher PG-SGA scores (group 2), although this difference was not significant when adjusting for other study variables.

Changes in the nutritional status of cancer patients can be attributed to the tumor's site of origin [23]. A study by Rodrigues and Chaves [10] revealed that women with ovarian cancer were more susceptible to nutritional status alterations, while those with endometrial cancer awere a less predisposed to such alterations, which corroborates our findings. Patients with ovarian cancer comprised the highest percentage of the group with higher scores (group 2). In another study by Chantragawee and Achariyapota [24], the authors assessed the prevalence of malnutrition in patients with gynecologic cancer using the PG-SGA and found that malnutrition was significantly more common among patients diagnosed with ovarian cancer than among those diagnosed with other types of cancer.

Perioperative fasting can exacerbate the surgical stress response, worsen insulin resistance, increase protein loss and impair gastrointestinal function. Moreover, preoperative fasting is associated with a series of consequences for patients, such as thirst, hunger, headache and anxiety [25]. The preoperative and postoperative fasting times were significantly shorter in group 1 and the initiation of oral feeding was not statistically significant between the groups. However, the early resumption of oral feeding in the immediate postoperative period was more prevalent in group 1 than in group 2, demonstrating that patients with worse PG-SGA scores fasted perioperatively for a longer time. Early resumption of oral intake after surgery is considered safe and vital for optimizing postoperative outcomes. Early oral feeding immediately after major surgery is associated with reduced postoperative complications, length of hospital stay and costs [25].

The classification of postoperative complications [18] differed significantly between the groups, with group 2 being the only group that presented a grade V complication, and was considered the most severe. Postoperative death was more frequent and statistically significant in group 2. Tortorella et al. [26] evaluated preoperative predictors of severe early complications in patients with gynecological neoplasms who underwent pelvic exenteration and reported that 27.9% of patients presented severe and early postoperative complications within 30 days after surgery. Among these patients, 24% had grade III complications, and 1.6% had grade IV complications. The mortality rate within 1 month after surgery was 2.3%.

Studies using the PG-SGA in women with gynecological cancer are scarce, highlighting the importance of the present study. The strengths of this study were the relatively large number of patients treated at a single institution, considered a reference center for the treatment of gynecological tumors, the analysis of several variables and the use of the PG-SGA score, providing a more accurate classification of nutritional status, allowing the identification of patients at risk of malnutrition and providing early intervention to maintain or recover the nutritional status of patients. The main limitation the retrospective design of the study, wich requires the exclusion of many patients due to the absence of data. Further studies are needed to prospectively assess the nutritional status of these patients before, during, and after surgical treatment and their outcomes.

In conclusion, the PG-SGA is a useful and feasible tool for assessing the nutritional status of patients with gynecological tumors, mainly through the use of the score. Patients with worse nutritional status had greater frequencies of developing severe postoperative complications, and increased odds of longer hospital stays and mortality. Identifying patients at nutritional risk or who are malnourished is of utmost importance for reducing the occurrence of postoperative complications, allowing interventions to optimize nutritional status before surgical intervention.

Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Competing Interests

The authors have no relevant financial or non-financial interests to disclose.

Author Contributions

Conceptualization: Bianca Cristina Antunes Alves Marques; Methodology: Bianca Cristina Antunes Alves Marques; Data collect: Leticia da Silva Jesus; Formal analysis and investigation: Bianca Cristina Antunes Alves Marques and Danúbia da Cunha Antunes Saraiva; Writing - original draft preparation: Leticia da Silva Jesus and Bianca Cristina Antunes Alves Marques; Writing - review and editing: Leticia da Silva Jesus, Bianca Cristina Antunes Alves Marques and Danúbia da Cunha Antunes Saraiva; Supervision: Bianca Cristina Antunes Alves Marques and Danúbia da Cunha Antunes Saraiva. All authors read and approved the final manuscript.

Ethics approval

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of the National Cancer Institute (12/27/2019/27285019.8.0000.5274).

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Association of Patient-Generated Subjective Global Assessment score with surgical outcomes in women with gynecologic cancer

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