In this US cohort of over 3,000 ambulatory solid tumor patients, nearly one-third were at high risk for MN at diagnosis. There was significant variation with the greatest risk of MN in those with lower GI, upper GI, and thoracic cancers, advanced stage disease, Black race, and higher symptom scores.
These striking results are consistent with oncology cohort studies, particularly those that included early-stage disease and breast cancer.28–30 Despite nearly one-third being at high risk of MN, our observed rate is lower than other studies which suggests variation in prevalence is driven by the specific oncology population. For example, in the prospective Italian PreMiO study, of nearly 2,000 ambulatory solid and hematologic cancer patients, 51% had MN based on the mini nutritional assessment, a validated measure of nutritional status in the elderly.7 This study, unlike the current analysis, included more GI cancers and higher rates of stage IV disease, both factors associated with higher rates of MN.
A notable observation was the high rates of MN in those with high BMI. Of those classified as overweight or obese by BMI, H-MST was observed in 24% and 20%, respectively. The obesity epidemic means 40–60% of all new cancer diagnoses present in those with obesity, and this new clinical picture likely reduces the identification of MN by practicing clinicians. A portion of these malnourished obese patients will have sarcopenia which is associated with poor oncologic outcomes.31,32 This further highlights the importance of MN screening and evaluation of sarcopenia in all cancer patients independent of weight or BMI at diagnosis.
Unique to this analysis and related to our catchment area, Black patients accounted for one-fifth of those studied. They had numerically higher H-MST rates than White or other races and this was independently associated with a nearly two-fold increase in high MN risk. Smaller US cancer studies using varied screening tools have not reported the prevalence of MN by race.30,33 Notably, Black race is correlated with higher MN rates in community-dwelling older adults in non-cancer populations.34 Sociodemographic factors, not included in the current analysis, disproportionately affects racial minorities and might also account for our findings and should be explored further in future investigations. The demographics analyzed suggest generalizability of these findings to other diverse US communities.
Aging, changes in end-organ function, and body composition remain well-documented risk factors for MN in non-cancer and cancer illnesses.35–37 In our sample, age was not an independent predictor of H-MST in multivariate analysis. We did, however, observe multiple symptoms to be independently associated with H-MST including depression, distress, fatigue, and trouble eating/swallowing. Studies of symptoms have observed their presence to be associated with a greater risk of MN, which appears to rise with age.38
Although this study identified MN risk in a large US cancer center, certain limitations are noteworthy. As a goal was to evaluate the prevalence of MN risk by clinicodemographic variables, we limited the analysis to persons with complete case records. A sensitivity analysis of all subjects found similar MST distribution with 27% H-MST and therefore our complete case analysis is likely representative of the larger cohort (Supplementary Table S1). Additionally, this was a cross-sectional analysis and included MST scores only at diagnosis. Third, our analysis was based only on patient self-reported MST. Lastly, due to limitations of the institutional database, we were unable to analyze the impact of MN on short- and long-term oncologic outcomes like treatment tolerability and survival.
MN screening remains uncommon in routine clinical care.39,40 The high risk of
MN in this cohort, including those with high BMI at diagnosis, support routine MN
screening at diagnosis. Future studies should evaluate ongoing screening
throughout the cancer trajectory. Understanding such findings will inform future
interventional studies targeting MN early, cost-benefit analyses, registered
dietitian nutritionist staffing patterns, and health outcomes in oncology.