Impact of improved nutritional status on survival in ovarian cancer

Predictive value of prognostic nutritional index for outcomes of cervical cancer: A systematic review and meta‑analysis

Cervical cancer is a major global health concern. Prognostic markers for cervical cancer have traditionally focused on tumor characteristics. However, there is a growing recognition of the importaxnce of the nutritional status of the patient as a possible prognostic indicator. The present meta-analysis aims to estimate the role of the prognostic nutritional index (PNI) in predicting overall survival (OS) and progression-free survival (PFS) in patients with cervical cancer. Medline, Google Scholar, Science Direct and Cochrane Central databases were systematically searched for studies reporting PNI in patients with cervical cancer. Inclusion criteria were applied to select relevant studies and data extraction was performed by two independent investigators. Risk of bias was assessed by the Newcastle-Ottawa Scale (NOS). The present meta-analysis included 10 studies with 2,352 participants. The pooled analysis showed that in patients with cervical cancer PNI did not have a significant prognostic utility in predicting OS [univariate hazard ration (HR): 1.38; 95% confidence interval (CI): 0.77-2.48) or PFS (univariate HR: 1.12; 95% CI: 0.44-2.68). These results were consistent even after adjusting for other confounders using multivariate analysis (pooled HR: 1.06 for OS; 95% CI: 0.64-1.76; pooled HR: 1.22 for PFS; 95% CI: 0.65-2.30). Subgroup analyses were also performed based on region, PNI cut-off, sample size, grade of evidence and treatment protocol and did not demonstrate any significant prognostic value of PNI. The funnel plot demonstrated symmetry, suggesting the absence of publication bias. The present meta-analysis indicated that PNI does not have a significant prognostic utility in predicting OS or PFS in women with cervical cancer. Further research is warranted to explore alternative nutritional indicators and identify reliable prognostic markers in this patient population.

Cancer-Related Malnutrition and the Role of Parenteral Nutrition in Cancer; A Narrative Review

The growing incidence rate of cancer and its associated morbidity and mortality prompts the need to identify factors that could improve the quality of life (QoL) and survival of a patient with cancer. Cancer-associated malnutrition is a common complication that could start at the early stages of cancer and could further develop into advanced cachexia. Response to treatment, length of hospital stay, progression of infection, and other complications of cancer including chemotherapy adverse events could all be influenced by the progression of malnutrition. Nutritional interventions may vary from oral to enteral and parenteral therapy. Parenteral nutrition (PN) therapy may benefit patients at certain stages of cancer in whom contraindications or inefficacy of other modalities of nutritional support are present. This method may seem invasive, costly, and risky but at the same time may improve certain patients' QoL and chance of survival. In trained settings with proper facilities, this method of nutritional support can benefit patients; However, the indication for starting PN must be carefully supervised considering that other nutritional support methods may be equally efficient and at the same time easier to access and apply.

Association between diet quality and ovarian cancer risk and survival

BACKGROUND

Research on diet quality and ovarian cancer is limited. We examined the association between diet quality and ovarian cancer risk and survival in a large prospective cohort.

METHODS

We used data from women in the prospective National Institutes of Health-AARP Diet and Health Study enrolled from 1995 to 1996 who were aged 50-71 years at baseline with follow-up through December 31, 2017. Participants completed a 124-item food frequency questionnaire at baseline, and diet quality was assessed via the Healthy Eating Index-2015, the alternate Mediterranean diet score, and the Dietary Approaches to Stop Hypertension score. Primary outcomes were first primary epithelial ovarian cancer diagnosis from cancer registry data and among those diagnosed with ovarian cancer all-cause mortality. We used a semi-Markov multistate model with Cox proportional hazards regression to account for semicompeting events.

RESULTS

Among 150 643 participants with a median follow-up time of 20.5 years, 1107 individuals were diagnosed with a first primary epithelial ovarian cancer. There was no evidence of an association between diet quality and ovarian cancer risk. Among those diagnosed with epithelial ovarian cancer, 893 deaths occurred with a median survival of 2.5 years. Better prediagnosis diet quality, according to the Healthy Eating Index-2015 (quintile 5 vs quintile 1: hazard ratio [HR] = 0.75, 95% confidence interval [CI] = 0.60 to 0.93) and alternate Mediterranean diet score (quintile 5 vs quintile 1: HR = 0.68, 95% CI = 0.53 to 0.87), was associated with lower all-cause mortality. There was no evidence of an association between Dietary Approaches to Stop Hypertension score and all-cause mortality.

CONCLUSIONS

Better prediagnosis diet quality was associated with lower all-cause mortality after ovarian cancer diagnosis but was not associated with ovarian cancer risk.

Nutritional interventions during treatment for ovarian cancer: A narrative review and recommendations for future research

Most women with ovarian cancer are diagnosed at an advanced stage (stage III or IV), when the intraabdominal spread of the tumour impacts nutrient intake and absorption. Up to 70 % of women with ovarian cancer are malnourished and approximately 40 % are affected by muscle loss at the time of diagnosis. Women with ovarian cancer are at high risk of nutritional decline due to invasive treatment and the severity of side-effects. This review explores the evidence evaluating nutritional interventions during treatment for ovarian cancer and their effect on nutritional status, muscle mass, and clinical outcomes. Perioperative immunonutrition has been investigated with mixed results for immediate postoperative outcomes. Individualised nutrition counselling as part of a multimodal prehabilitation programme prior to surgery shows promising results; however, the effects are limited by sample size. Nutrition counselling as part of a mixed intervention with exercise shows high acceptability and suggests improvements in dietary intake and quality of life during chemotherapy treatment, while oral nutritional supplements and nutrition education appear to reduce symptom burden. Individualised nutrition counselling during treatment also appears to be associated with improved overall survival; however, the evidence is limited to a single retrospective study. A key finding from this review is that, despite the high prevalence of malnutrition and muscle loss in women with ovarian cancer and the critical importance of addressing these modifiable prognostic factors, nutrition intervention studies are limited. Prospective studies with samples large enough to provide adequate power to evaluate intervention effectiveness are urgently required to inform optimal management.

Trends in nutritional status and factors affecting prognostic nutritional index in ovarian cancer patients during chemotherapy: a prospective longitudinal study based on generalized estimating equations

PURPOSE

Numerous studies have investigated the relationships between nutritional status and the prognosis of ovarian cancer (OC). However, the majority of these studies have focused on pre-chemotherapy malnutrition, with limited attention given to dynamic changes in nutritional status during chemotherapy and the associated risk factors affecting the prognostic nutritional index (PNI) in OC women. This study aims to explore the variation trend in the nutritional status of OC women over time during chemotherapy and assess its predictive factors.

METHODS

A prospective longitudinal study was conducted from January 2021 to August 2023. Body mass index (BMI), PNI, Nutritional Risk Screening (NRS) 2002, serum albumin, and prealbumin measurements were utilized to assess the nutritional status of OC women. Data were collected through face-to-face interviews before initial chemotherapy (T0) and during the first (T1), third (T2), and fifth (T3) cycles of chemotherapy. Generalized Estimating Equations (GEE) were employed for the analysis of potential predictive factors.

RESULTS

A total of 525 OC women undergoing chemotherapy completed the study. Significantly varied levels of BMI, PNI, and serum concentrations of hemoglobin, albumin, prealbumin, potassium, sodium, magnesium, and calcium were observed in these patients (p < 0.05). The prevalence of nutritional risk decreased over time during chemotherapy (p < 0.05). Nutritional parameters, including BMI, PNI, and the serum concentrations of albumin and prealbumin, exhibited an upward trend in nutritional status throughout the chemotherapy cycles (p < 0.05). Multivariate analysis indicated that higher levels of BMI, serum albumin, prealbumin, absolute lymphocyte count, and hemoglobin ≥ 110 g/L at admission were associated with elevated PNI after chemotherapy (β = 0.077, p = 0.028; β = 0.315, p < 0.001; β = 0.009, p < 0.001; β = 1.359, p < 0.001; β =  - 0.637, p = 0.005).

CONCLUSION

Patients consistently demonstrated improvements in nutritional risk and status from the initiation to the completion of chemotherapy cycles. Nutritional monitoring of OC women, particularly those exhibiting abnormalities at the commencement of chemotherapy, is crucial. Targeted nutritional support programs should be developed to enhance the prognosis of OC women.

Nutritional Assessment Tools for Patients with Cancer: A Narrative Review

Cancer patients are at high risk of malnutrition, which can lead to adverse health outcomes such as prolonged hospitalization, increased complications, and increased mortality. Accurate and timely nutritional assessment plays a critical role in effectively managing malnutrition in these patients. However, while many tools exist to assess malnutrition, there is no universally accepted standard. Although different tools have their own strengths and limitations, there is a lack of narrative reviews on nutritional assessment tools for cancer patients. To address this knowledge gap, we conducted a non-systematic literature search using PubMed, Embase, Web of Science, and the Cochrane Library from their inception until May 2023. A total of 90 studies met our selection criteria and were included in our narrative review. We evaluated the applications, strengths, and limitations of 4 commonly used nutritional assessment tools for cancer patients: the Subjective Global Assessment (SGA), Patient-Generated Subjective Global Assessment (PG-SGA), Mini Nutritional Assessment (MNA), and Global Leadership Initiative on Malnutrition (GLIM). Our findings revealed that malnutrition was associated with adverse health outcomes. Each of these 4 tools has its applications, strengths, and limitations. Our findings provide medical staff with a foundation for choosing the optimal tool to rapidly and accurately assess malnutrition in cancer patients. It is essential for medical staff to be familiar with these common tools to ensure effective nutritional management of cancer patients.

Pre-Operative Malnutrition in Patients with Ovarian Cancer: What Are the Clinical Implications? Results of a Prospective Study

BACKGROUND

Malnutrition was associated with worse survival outcomes, impaired quality of life, and deteriorated performance status across various cancer types. We aimed to identify risk factors for malnutrition in patients with epithelial ovarian cancer (EOC) and impact on survival.

METHODS

In our prospective observational monocentric study, we included the patients with primary and recurrent EOC, tubal or peritoneal cancer conducted. We assessed serum laboratory parameters, body mass index, nutritional risk index, nutritional risk screening score (NRS-2002), and bio-electrical impedance analysis.

RESULTS

We recruited a total of 152 patients. Patients > 65 years-old, with ascites of >500 mL, or with platinum-resistant EOC showed statistically significant increased risk of malnutrition when evaluated using NRS-2002 (p-values= 0.014, 0.001, and 0.007, respectively). NRS-2002 < 3 was an independent predictive factor for complete tumor resectability (p = 0.009). The patients with NRS-2002 ≥ 3 had a median overall survival (OS) of seven months (95% CI = 0-24 months), as compared to the patients with NRS-2002 < 3, where median OS was forty-six months (p = 0.001). A phase angle (PhAα) ≤ 4.5 was the strongest predictor of OS.

CONCLUSIONS

In our study, we found malnutrition to be an independent predictor of incomplete cytoreduction and independent prognostic factor for poor OS. Preoperative nutritional assessment is an effective tool in the identification of high-risk EOC groups characterized by poor clinical outcome.

Association of protein intake with recurrence and survival following primary treatment of ovarian cancer

BACKGROUND

Malnutrition is common during treatment for ovarian cancer and one in three report multiple symptoms affecting food intake after primary treatment. Little is known about diet post-treatment in relation to ovarian cancer survival, however, general recommendations for cancer survivors are to maintain a higher level of protein intake to support recovery and minimize nutritional deficits.

OBJECTIVE

To investigate whether intake of protein and protein food sources following primary treatment for ovarian cancer is associated with recurrence and survival.

DESIGN

Intake levels of protein and protein food groups were calculated from dietary data collected about 12 months post-diagnosis using a validated food frequency questionnaire in an Australian cohort of females with invasive epithelial ovarian cancer. Disease recurrence and survival status were abstracted from medical records (median 4.9 years follow-up). Cox proportional hazards regression was used to calculate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for protein intake and progression-free and overall survival.

RESULTS

Among 591 females who were progression-free at 12-months follow-up, 329 (56%) subsequently experienced cancer recurrence and 231 (39%) died. A higher level of protein intake was associated with better progression-free survival (>1-1.5 vs. ≤1 grams per kilogram body weight (g/kg): HR_adjusted=0.69, 95% CI 0.48, 1.00; >1.5 vs. ≤1g/kg: HR_adjusted=0.61, 95% CI 0.41, 0.90; >20% vs. ≤20% total energy intake from protein: HR_adjusted=0.77, 95% CI 0.61, 0.96). There was no evidence for better progression-free survival with any particular protein food sources. There was a suggestion of better overall survival among those with higher total intakes of animal-based protein foods, particularly dairy products (HR=0.71, 95% CI 0.51, 0.99 for highest vs. lowest tertiles of total dairy intake).

CONCLUSIONS

After primary treatment for ovarian cancer, a higher level of protein intake may benefit progression-free survival. Ovarian cancer survivors should avoid dietary practices that limit intake of protein-rich foods.

The Effect of Body Mass Index and Residence in Food Priority Areas on Patterns-of-Care and Cancer Outcomes in Patients With Stage III Non-Small Cell Lung Cancer

PURPOSE

Patients living in food priority areas (FPAs), where access to healthy meals is challenging, may be at greater risk of nutritional deficits, leading to poorer cancer outcomes. Currently, there are no published data analyzing how FPAs affect patterns-of-care or outcomes for patients with locally advanced non-small cell lung cancer (NSCLC). We aimed to analyze the effect of residing in an FPA on treatments rendered and cancer outcomes in patients with stage III NSCLC treated at a single institution.

METHODS AND MATERIALS

This is a retrospective study of 573 patients with locally advanced NSCLC consecutively treated from January 2000 to January 2020. χ² and Mann-Whitney U tests were performed to determine differences between select variables. Kaplan-Meier analysis and Cox proportional hazard models were used to analyze overall survival (OS) and freedom from recurrence. Cox regression with forward model selection was used for multivariate analysis.

RESULTS

Thirty-two percent of patients resided in an FPA (n = 183) and were more likely to self-identify as Black (P < .0001), single (P < .001), <60 years of age (P = .001), and uninsured (P < .0001), with a lower median income (P < .001). Patients in FPAs also had lower mean pre-chemoradiation (CRT) albumin (P = .002), lower pre-CRT body mass index (BMI) (P = .026), and were less likely to receive trimodality therapy (P ≤ .001) compared with patients not living in FPAs. There was no difference in OS or freedom from recurrence between the 2 cohorts. However, in patients with a normal BMI, either pre-CRT (median OS, 18.4 vs 25.0 months; P = .005) or after CRT (15.1 vs 28.1 months, P = .002), residing in an FPA resulted in an OS detriment.

CONCLUSIONS

We demonstrated a clear socioeconomic divide in our patient population with stage III NSCLC, where residing in FPAs was associated with less-aggressive therapy and an OS detriment for patients with a normal-weight BMI. We are currently conducting a prospective study characterizing the nutritional needs of patients, particularly those who live in FPAs.

Total Polyunsaturated Fatty Acid Level in Abdominal Adipose Tissue as an Independent Predictor of Recurrence-Free Survival in Women with Ovarian Cancer

Prognostic factors for epithelial ovarian cancers (EOCs) are in particular clinical factors such as pathology staging at diagnosis (FIGO stages), genetic mutation, or histological phenotypes. In the present study, FIGO stage, tumor residue after surgery, and body mass index were clinical predictors of recurrence-free survival (RFS). Nonetheless, a number of studies support a lipid metabolism disorder in ovarian cancer patients. The objective of this pilot study was to explore whether fatty acid composition of adipose reflecting the qualitative dietary intake and fatty acids metabolism may be associated with RFS. Forty-six women with EOCs and six with borderline ovarian tumors between March 2017 and January 2020 were included in this prospective study at Tours university teaching hospital (central France). The patients involved in the present study are part of the METERMUS trial (clinicaltrials.gov NCT03027479). Adipose tissue specimens from four abdominal locations (superficial and deep subcutaneous, visceral (pericolic), and omental) were collected during surgery or exploratory laparoscopy. A fatty acid profile of adipose tissue triglycerides was established by gas chromatography. Fatty acids composition was compared among the four locations using nonparametric Friedman’s ANOVA test for repeated measures. Median follow-up of EOC patients was 15 months and patients’ RFS was analyzed using Kaplan−Meier survival curves and log-rank test by separating patients into two groups according to median fatty acid levels. The content of long-chain saturated fatty acids (SFAs) was increased and that of long-chain polyunsaturated fatty acids (PUFAs) decreased in deep versus superficial subcutaneous adipose tissue in EOC patients. Nevertheless, the content of total SFAs was ~28%, monounsaturated fatty acids (MUFAs) ~55%, PUFAs n-6 ~11.5%, and PUFAs n-3 about 1.3%, whatever the adipose tissue. When EOC patients were separated into two groups by median fatty acid content, total PUFAs (n-6+n-3) levels, whatever the adipose tissue, were positively and independently associated with RFS. RFS was about two times longer in EOC patients with high versus low total PUFA content (median survival: 12 vs. 27 months, p = 0.01 to <0.0001 according to the tissue). Content of total PUFAs (n-6+n-3) in abdominal adipose tissue (visceral and subcutaneous) are new prognostic factors in EOC.

Supplemental parenteral nutrition in cancer care: why, who, when

Malnutrition is an often-overlooked challenge for patients with cancer. It is associated with muscle mass reduction, poor compliance and response to cancer treatments, decreased quality of life, and reduced survival time. The nutritional assessment and intervention should be a vital part of any comprehensive cancer treatment plan. However, data on artificial nutrition supplied based on caloric needs during cancer care are scarce. In this review, we discuss the recommendations of the European and American societies for clinical nutrition on the use of nutritional interventions in malnourished patients with cancer in the context of current clinical practice. In particular, when enteral nutrition (oral or tube feeding) is not feasible or fails to meet the complete nutritional needs, supplemental parenteral nutrition (SPN) can bridge the gap. We report the available evidence on SPN in cancer patients and identify the perceived barriers to the wider application of this intervention. Finally, we suggest a ‘permissive’ role of SPN in cancer care but highlight the need for rigorous clinical studies to further evaluate the use of SPN in different populations of cancer patients.

The feasibility of screening for malnutrition in the outpatient setting and the prevalence of malnutrition in patients with newly-diagnosed ovarian carcinoma

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Malnutrition screening of outpatients in a Gynecologic Oncology clinic setting is feasible.

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Malnutrition was infrequently detected through outpatient screening of new patients with suspected gynecologic malignancy.

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The prevalence of malnutrition in individuals with newly-diagnosed ovarian cancer is low.

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Optimizing nutrition remains important, especially later in the cancer course when malnutrition is likely more prevalent.

Introduction

Methods

Results

Conclusion

Association between Energy Balance-Related Factors and Clinical Outcomes in Patients with Ovarian Cancer: A Systematic Review and Meta-Analysis

Background: This systematic review and meta-analysis synthesized evidence in patients with ovarian cancer at diagnosis and/or during first-line treatment on; (i) the association of body weight, body composition, diet, exercise, sedentary behavior, or physical fitness with clinical outcomes; and (ii) the effect of exercise and/or dietary interventions. Methods: Risk of bias assessments and best-evidence syntheses were completed. Meta-analyses were performed when ≥3 papers presented point estimates and variability measures of associations or effects. Results: Body mass index (BMI) at diagnosis was not significantly associated with survival. Although the following trends were not supported by the best-evidence syntheses, the meta-analyses revealed that a higher BMI was associated with a higher risk of post-surgical complications (n = 5, HR: 1.63, 95% CI: 1.06−2.51, p = 0.030), a higher muscle mass was associated with a better progression-free survival (n = 3, HR: 1.41, 95% CI: 1.04−1.91, p = 0.030) and a higher muscle density was associated with a better overall survival (n = 3, HR: 2.12, 95% CI: 1.62−2.79, p < 0.001). Muscle measures were not significantly associated with surgical or chemotherapy-related outcomes. Conclusions: The prognostic value of baseline BMI for clinical outcomes is limited, but muscle mass and density may have more prognostic potential. High-quality studies with comprehensive reporting of results are required to improve our understanding of the prognostic value of body composition measures for clinical outcomes. Systematic review registration number: PROSPERO identifier CRD42020163058.

Risk Factors for Anastomotic Leakage in Advanced Ovarian Cancer Surgery: A Large Single-Center Experience

Background

Cytoreductive surgery is currently the main treatment for advanced epithelial ovarian cancer (OC), and several surgical maneuvers, including colorectal resection, are often needed to achieve no residual disease. High surgical complexity carries an inherent risk of postoperative complications, including anastomosis leakage (AL). Albeit rare, AL is a life-threatening condition. The aim of this single-center retrospective study is to assess the AL rate in patients undergoing colorectal resection and anastomosis during primary surgery for advanced epithelial OC through a standardized surgical technique and to evaluate possible pre/intra- and postoperative risk factors to identify the population at greatest risk.

Methods

A retrospective analysis of clinical and surgical characteristics of 515 patients undergoing colorectal resection and anastomosis during primary or interval debulking surgery between December 2011 and October 2019 was performed. Several pre/intra- and postoperative variables were evaluated by multivariate analysis as potential risk factors for AL.

Results

The overall anastomotic leakage rate was 2.9% (15/515) with a significant negative impact on postoperative course. Body mass index < 18 kg/m², preoperative albumin value lower than 30 mg/dL, section of the inferior mesenteric artery at its origin, and medium–low colorectal anastomosis (< 10 cm from the anal verge) were identified as independent risk factors for AL on multivariate analysis.

Conclusions

AL is confirmed to be an extremely rare but severe postoperative complication of OC surgery, being responsible for increased early postoperative mortality. Preoperative nutritional status and surgical characteristics, such as blood supply and anastomosis level, appear to be the most significant risk factors.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-022-11686-y.

Progress in Applicability of Scoring Systems Based on Nutritional and Inflammatory Parameters for Ovarian Cancer

Ovarian cancer is a malignancy that seriously endangers women’s health; its case fatality rate ranks first among the gynecological malignancies. The status of nutrition of ovarian cancer patients is related to their prognoses. Thus, it is important to evaluate, monitor, and improve the nutritional status of ovarian cancer patients during their treatment. Currently, there are several tools for examining malnutrition and nutritional assessment, including NRI (nutrition risk index), PG-SGA (patient-generated subjective global assessment), and NRS 2002 (nutritional risk screening 2002). In addition to malnutrition risk examination and related assessment tools, the evaluation of muscle mass, C-reactive protein, lymphocytes, and other inflammation status indicators, such as neutrophils to lymphocytes ratio, lymphocyte-to-monocyte ratio, and C-reactive protein-albumin ratio, is of great importance. The nutritional status of ovarian cancer patients undergoing surgery affects their postoperative complications and survival rates. Accurate evaluation of perioperative nutrition in ovarian cancer patients is crucial in clinical settings. An intelligent nutritional diagnosis can be developed based on the results of its systematic and comprehensive assessment, which would lay a foundation for the implementation of personalized and precise nutritional therapy.

Nutrition risk screening and implications for patients with gynaecological cancers undergoing pelvic radiotherapy and/or other treatment modalities: A retrospective observational study

AIM

There is scarcity of research for the nutritional management of pelvic radiotherapy in gynaecological malignancies and delivery of specialised nutrition care is limited due to the current knowledge gap in guidelines. This study aimed to better understand the nutritional risk, weight changes and pattern of nutrition impact symptoms occurring at various treatment timepoints in this population, to inform an effective model of care.

METHODS

This retrospective, observational study included women with gynaecological cancers receiving pelvic radiotherapy at a tertiary hospital from January 2017 to December 2018 (n = 104). Information was collected on: first day of radiotherapy; weekly during treatment; acute-phase post-treatment (0-6 weeks); and intermediate-phase post-treatment (6 weeks to 6 months). This study reported on incidence of clinically significant weight change (±5%), documented nutrition impact symptoms and the current nutrition care model (nutrition screening, referral, assessment and interventions).

RESULTS

Clinically significant weight loss was experienced by 38% (n = 40/104) of patients prior to commencing treatment and 19% (n = 14/73) during treatment. Diarrhoea (n = 40/79), fatigue (n = 54/79), nausea (n = 38/79) and pain (n = 31/79) were frequently reported during treatment, and fatigue (n = 33/92) and pain (n = 25/92) continued acutely post-treatment. Despite high rates of weight loss and prevalence of nutrition impact symptoms, only 38% (n = 40/104) of patients were referred to a dietitian.

CONCLUSIONS

A considerable proportion of patients with gynaecological cancers are at nutrition risk before and during treatment due to clinically significant weight loss and prevalence of nutrition impact symptoms experienced. This highlights the importance of nutrition-risk screening and access to specialised dietetic care as part of their model of care.

Research Status and Progress of Nutritional Support Therapy for Ovarian Cancer

Ovarian cancer is one of the most fatal gynecological cancers. For most ovarian cancer patients, nutritional risk or malnutrition may accompany them for life. Regular nutritional risk screening, timely nutritional assessment and necessary nutritional treatment play an extremely important role in the process of comprehensive treatment of ovarian cancer. The nutritional status and influence of ovarian cancer patients, preoperative screening and assessment of nutritional risk, preoperative and postoperative nutritional treatment indicate that nutritional treatment of ovarian cancer is one of the key factors in the treatment of cancer. We have summarized the status and progress of nutritional support therapy for ovarian cancer. We are aimed to improve the understanding of the impact of nutritional support therapy for ovarian cancer and to guide the clinical work.

Dietitian encounters after treatment for ovarian cancer

BACKGROUND

After ovarian cancer treatment, women report health issues that may be amenable to change with dietary support. The present study investigated how many women encounter a dietitian post-treatment and the factors associated with dietitian service use.

METHODS

We used data from a cohort of women with invasive epithelial ovarian cancer to identify socio-economic, clinical and personal factors associated with dietitian encounter after treatment completion. Data were collected at regular intervals using validated questionnaires up to 4 years post-treatment completion. Logistic regression (LR) and generalised linear mixed models (GLMM) were used to calculate adjusted odds ratios (OR) and 95% confidence intervals (CI) to assess factors associated with dietitian encounter at any time-point post-treatment (LR), as well as in the 3 months prior to a follow-up questionnaire (GLMM) to assess time-varying factors.

RESULTS

Of 819 women, 97 (12%) reported seeing a dietitian post-treatment. Factors associated with dietitian encounter were being overweight (OR_LR  = 1.7, CI = 1.1-2.8), having poorer self-rated health (OR_LR  = 2.5, CI = 1.2-5.2; OR_GLMM  = 2.3, CI = 1.2-4.4) or poorer diet quality (OR_LR  = 0.5, CI = 0.2-1.0) pre-diagnosis, treatment within the public health system (OR_GLMM  = 1.8, CI = 1.2-2.7), previous support from dietetic (OR_LR  = 3.1, CI = 1.8-5.4; OR_GLMM  = 2.8, CI = 1.8-4.2) or other allied health services (OR_LR  = 2.0, CI = 1.2-3.2; OR_GLMM  = 3.7, CI = 2.4-5.5), and having progressive disease at follow-up (OR_GLMM  = 2.2, CI = 1.4-3.3). Most women (86%) with ≥ 3 moderate-to-severe nutrition impact symptoms did not report a dietitian encounter post-treatment.

CONCLUSIONS

Few women encounter a dietitian post-treatment for ovarian cancer, including those with multiple nutrition impact symptoms. Further work is needed to engage those likely to benefit from dietitian support but less likely to seek or receive it.

Pretreatment Prognostic Nutritional Index (PNI) as a Prognostic Factor in Patients with Biliary Tract Cancer: A Meta-Analysis

OBJECTIVE

Many reports have shown that the prognostic nutritional index (PNI) is associated with the clinical outcomes of patients with biliary tract cancer (BTC), with the results being inconsistent. We therefore comprehensively evaluated the prognostic significance of the PNI in BTC by performing a meta-analysis.

METHODS

We identified relevant studies by searching PubMed, Embase, Web of Science and, the Cochrane Library. The combined hazard ratio (HR) and odds ratio (OR) with 95% confidence interval (CI) were used to evaluate the association between PNI and overall survival (OS) and the clinical characteristics of BTC.

RESULTS

We included seven studies with 1608 patients in this meta-analysis. The pretreatment low PNI correlated significantly with worse OS (HR = 1.65, 95%CI = 1.42-1.93, p < 0.001). In addition, the prognostic effect of PNI are reliable in different subgroups of ethnicity, sample size, histology, treatment, PNI cutoff, and cutoff determination. The low PNI was also related to poor differentiation (OR = 1.95, 95%CI = 1.34-2.85, p = 0.001) as well as higher T stage (OR = 2.51, 95%CI = 1.69-3.74, p < 0.001) in BTC.

CONCLUSION

The low PNI is significantly associated with inferior prognosis of patients with BTC and aggressive clinical factors. The PNI could be applied as an independent prognostic marker for patients with BTC.

Nutrition in Cancer: Evidence and Equality

PURPOSE

Poor nutrition is highly implicated in the pathogenesis of cancer and affects the survival of patients during and after completion of definitive therapies. Mechanistic evidence accumulated over the last century now firmly places dysregulated cellular energetics within the emerging hallmarks of cancer. Nutritional intervention studies often aim to either enhance treatment effect or treat nutritional deficiencies that portend poor prognoses. Patients living within food priority areas have a high risk of nutritional need and are more likely to develop comorbidities, including diabetes, hypertension, renal disease, and cardiovascular risk factors. Unfortunately, there is currently a paucity of data analyzing the impact of food priority areas on cancer outcomes.

METHODS

Therefore, we performed a review of the literature focusing on the molecular and clinical interplay of cancer and nutrition, the importance of clinical trials in elucidating how to intervene in this setting and the significance of including citizens who live in food priority areas in these future prospective studies.

CONCLUSIONS

Given the importance of nutrition as an emerging hallmark of cancer, further research must be aimed at directing the optimal nutrition strategy throughout oncologic treatments, including the supplementation of nutritious foods to those that are otherwise unable to attain them.

Serum Concentrations of Carotenoids and Fat-Soluble Vitamins in Relation to Nutritional Status of Patients with Ovarian Cancer

In this study, we aimed to determine serum concentrations of carotenoids and fat-soluble vitamins (FSVs) in ovarian cancer (OC) patients categorized by clinical and nutritional status and to compare obtained results with healthy controls. We used single-step extraction methods throughout the study. Serum concentrations of the bioactive compounds were measured using HPLC. The evaluation of the nutritional status of patients was performed with scored PG-SGA questionnaire.The serum bioactive compound levels were significantly lower in early-stage OC patients (FIGO I/II) when compared to healthy controls for all-trans-retinoic acid, 25-hydroxycholecalciferol, all-trans-retinol, astaxanthin, zeaxanthin, lycopene and α-carotene, respectively. In patients with advanced-stage of OC (FIGO III/IV) the mean serum concentrations of carotenoids and FSVs were significantly lower than in healthy controls, excluding lutein and β + γ-tocopherol levels. Patients with OC and concomitant moderate or severe malnourishment showed significantly lower levels of 25-hydroxycholecalciferol and all-trans-retinol. It seems that our extraction and measurement methods for the bioactive compounds could be used in both, clinical and nutritional studies. The obtained results confirm that the PG-SGA assessment might be considered not only as a malnutrition assessment tool, but also for planning early nutritional intervention in patients with OC.

Preoperative C-reactive protein-to-albumin ratio predicts long-term outcomes in extrahepatic cholangiocarcinoma patients

BACKGROUND

Systemic inflammation may have prognostic value in some malignancies and association with lymph node metastasis. This study aimed to evaluate the impact of systemic inflammatory biomarkers on long-term and oncological outcomes as well as to assess the association between biomarkers with lymph node metastasis in extrahepatic cholangiocarcinoma patients.

METHODS

We enrolled 271 consecutive patients who underwent surgical resection for extrahepatic cholangiocarcinoma. Poor prognostic factors were compared to identify the biomarkers that were most associated with overall survival (OS) and disease-free survival (DFS) using receiver operating characteristic curves and multivariable analysis. Furthermore, we evaluated the relationship between biomarkers and lymph node metastasis.

RESULTS

Four and two biomarkers were predictive for OS and DFS, respectively, among which, the C-reactive protein-to-albumin ratio (CAR) had the highest area under the curve values (OS: 0.631, DFS: 0.624). Multivariable analysis showed that a high CAR was an independent prognostic factor for both OS and DFS (P = .002 and P < .001, respectively). Although a high CAR was not significantly correlated with lymph node metastasis (P = .645), carbohydrate antigen 19-9 showed a significant correlation (P < .001).

CONCLUSIONS

Preoperative CAR is the most accurate prognostic factor for OS and DFS in extrahepatic cholangiocarcinoma patients and is independent of lymph node metastasis.

Malnutrition Screening: An Interprofessional Approach in Outpatient Oncology

BACKGROUND

Malnutrition is highly prevalent in the oncology population and is associated with poor treatment outcomes.

OBJECTIVES

This study aimed to implement a malnutrition screening process using a validated tool in three outpatient cancer centers.

METHODS

Nursing and nutrition department leaders collaborated to establish malnutrition screening. The Malnutrition Screening Tool (MST) was embedded in the electronic health record. Based on the MST, a score of 2 or greater is considered at risk for malnutrition. Nurses were educated on screening all patients completing their first cycle of infusion chemotherapy. Data were collected for six months.

FINDINGS

Interprofessional collaboration established a process to implement malnutrition screening. Twenty-eight percent of patients with cancer were at risk for malnutrition. Fifty-three percent were at risk for malnutrition based on MST scores of 2. Compliance with the MST at first infusion visit was 30%-81% across the three cancer centers.

Skeletal muscle mass as a prognostic indicator of outcomes in ovarian cancer: a systematic review and meta-analysis

BACKGROUND

Muscle mass plays a key role in predicting clinical outcomes in cancer. This systematic review and meta-analysis aimed to evaluate whether computed tomography (CT) scan indexes of muscle mass quantity and quality could be used as prognostic factors in ovarian cancer.

METHODS

Three electronic bibliographic databases (MEDLINE, Web of Science, and Cochrane Central Register of Controlled Trials) were used to conduct a systematic literature search from inception to January 2020. The primary outcome was overall survival. Pooled analyses of hazard ratios (HRs) and 95% confidence intervals (CIs) were performed with Review Manager 5.3. Heterogeneity was assessed by measuring inconsistency (I2 based on the χ2 test). Secondary outcomes included progression free survival, disease free survival, postoperative complications, and chemotoxicity. Study quality and quality of evidence were assessed.

RESULTS

A total of 15 studies were included in the systematic review, of which six studies (1226 patients) were included in the meta-analysis. Summary unadjusted HRs (HR 1.11, 95% CI 0.84 to 1.46, p=0.47) and adjusted HRs (HR 1.10, 95% CI 0.84 to 1.43, p=0.49) did not show a significant association between low skeletal muscle index and overall survival (p>0.05) in ovarian cancer. Instead, although the quality of evidence was low, pooled data of three studies, comprising 679 patients, showed a significant association between low skeletal muscle radiodensity and poor overall survival (HR 1.63, 95% CI 1.28 to 2.07, p<0.0001). Moreover, the heterogeneity between studies precluded the possibility of performing a meta-analysis and reaching conclusions for progression free survival, disease free survival, surgical complications, and chemotoxicity.

CONCLUSIONS

This work suggested that the measurement of skeletal muscle radiodensity by routine CT scan at diagnosis, with standardization of diagnostic criteria, could be a reliable tool to select at risk patients and to individualize effective nutritional strategies. However, prospective homogeneous studies with a larger number of patients are required to confirm these results.

Nutritional Aspect of Cancer Care in Medical Oncology Patients

PURPOSE

Awareness of advances in the nutritional aspects of cancer care and translation of this information into clinical practice are important for oncology practitioners to effectively couple oncologic and nutritional approaches throughout the cancer journey. The goal of this consensus statement by a panel of medical oncologists was to provide practical and implementable guidance addressing nutritional aspects of cancer care from the perspective of the medical oncologist.

METHODS

A panel of medical oncologists agreed on a series of statements supported by scientific evidence and expert clinical opinion.

FINDINGS

Participating experts emphasized that both poor nutritional intake and metabolic alterations underlie cancer-related malnutrition. The use of liquid and high energy-dense oral nutritional supplements may enable better patient compliance, whereas higher efficacy is more likely with the use of pharmaconutrient-enriched oral nutritional supplements in terms of improved weight, lean body mass, functional status, and quality of life, as well as better tolerance to antineoplastic treatment. A multimodal approach is currently believed to be the best option to counteract the catabolism leading to cancer-related malnutrition; this treatment is scheduled in parallel with anticancer therapies and includes nutritional interventions, multitarget drug therapies, and exercise and rehabilitation programs. Participating experts emphasized the role of the oncologist as a reference professional figure in the coordination of nutritional care for patients with cancer within the context of complex and different clinical scenarios, particularly for permissive-adjunctive nutritional support.

IMPLICATIONS

This review article provides practical guidance addressing major nutritional aspects of cancer care from the medical oncologist's perspective. Thus, this document is expected to assist oncology practitioners in terms of awareness of advances in the nutritional aspects of cancer care and translation of this information into their clinical practice to effectively couple oncologic and nutritional approaches as part of the continuum of care for patients with cancer.

Nutritional Interventions to Improve Clinical Outcomes in Ovarian Cancer: A Systematic Review of Randomized Controlled Trials

Among all gynaecological neoplasms, ovarian cancer has the highest rate of disease-related malnutrition, representing an important risk factor of postoperative mortality and morbidity. Hence, the importance of finding effective nutritional interventions is crucial to improve ovarian cancer patient's well-being and survival. This systematic review of randomized controlled trials (RCTs) aims at assessing the effects of nutritional interventions on clinical outcomes such as overall survival, progression-free survival, length of hospital stay (LOS), complications following surgery and/or chemotherapy in ovarian cancer patients. Three electronic bibliographic databases (MEDLINE, Web of Science, and Cochrane Central Register of Controlled Trials) were used to conduct a systematic literature search based on fixed inclusion and exclusion criteria, until December 2018. A total of 14 studies were identified. Several early postoperative feeding interventions studies (n = 8) were retrieved mainly demonstrating a reduction in LOS and an ameliorated intestinal recovery after surgery. Moreover, innovative nutritional approaches such as chewing gum intervention (n = 1), coffee consumption (n = 1), ketogenic diet intervention (n = 2) or fruit and vegetable juice concentrate supplementation diet (n = 1) and short-term fasting (n = 1) have been shown as valid and well-tolerated nutritional strategies improving clinical outcomes. However, despite an acceptable number of prospective trials, there is still a lack of homogeneous and robust endpoints. In particular, there is an urgent need of RCTs evaluating overall survival and progression-free survival during ovarian oncology treatments. Further high-quality studies are warranted, especially prospective studies and large RCTs, with more homogeneous types of intervention and clinical outcomes, including a more specific sampling of ovarian cancer women, to identify appropriate and effective nutritional strategies for this cancer, which is at high risk of malnutrition.

Nutritional Interventions to Improve Clinical Outcomes in Ovarian Cancer: A Systematic Review of Randomized Controlled Trials

Among all gynaecological neoplasms, ovarian cancer has the highest rate of disease-related malnutrition, representing an important risk factor of postoperative mortality and morbidity. Hence, the importance of finding effective nutritional interventions is crucial to improve ovarian cancer patient's well-being and survival. This systematic review of randomized controlled trials (RCTs) aims at assessing the effects of nutritional interventions on clinical outcomes such as overall survival, progression-free survival, length of hospital stay (LOS), complications following surgery and/or chemotherapy in ovarian cancer patients. Three electronic bibliographic databases (MEDLINE, Web of Science, and Cochrane Central Register of Controlled Trials) were used to conduct a systematic literature search based on fixed inclusion and exclusion criteria, until December 2018. A total of 14 studies were identified. Several early postoperative feeding interventions studies (n = 8) were retrieved mainly demonstrating a reduction in LOS and an ameliorated intestinal recovery after surgery. Moreover, innovative nutritional approaches such as chewing gum intervention (n = 1), coffee consumption (n = 1), ketogenic diet intervention (n = 2) or fruit and vegetable juice concentrate supplementation diet (n = 1) and short-term fasting (n = 1) have been shown as valid and well-tolerated nutritional strategies improving clinical outcomes. However, despite an acceptable number of prospective trials, there is still a lack of homogeneous and robust endpoints. In particular, there is an urgent need of RCTs evaluating overall survival and progression-free survival during ovarian oncology treatments. Further high-quality studies are warranted, especially prospective studies and large RCTs, with more homogeneous types of intervention and clinical outcomes, including a more specific sampling of ovarian cancer women, to identify appropriate and effective nutritional strategies for this cancer, which is at high risk of malnutrition.

Nutritional and metabolic derangements in Mediterranean cancer patients and survivors: the ECPC 2016 survey

BACKGROUND

The prevalence of nutritional derangements in patients with cancer is high. This survey assessed patients' awareness of cancer-related nutritional issues and evaluated how important they perceive the impact of nutrition on cancer and treatment to be.

METHODS

A structured questionnaire was developed to determine: presence of feeding problems, perception of nutrition importance, and perception of physicians' approach to nutrition. The European Cancer Patient Coalition disseminated the questionnaire to its members in 10 countries. The Mediterranean cluster (Italy, Spain, and Greece) was analysed separately to further determine specific patterns in answers.

RESULTS

In total, 907 respondents completed the questionnaire (68.8% female participants; 51.7% with cancer; 48.3% cancer survivors; 59.3% diagnosed with cancer ≤3 years ago; 46.2% receiving treatment for <1 year). Feeding problems during illness/therapy were experienced by 72.5% (628/867) of all respondents (Italian: 90.0%, 117/130), although up to 53.9% (467/867) reported that physicians did not check their feeding status. Overall, 69.6% (586/842) of respondents reported weight loss after cancer diagnosis (moderate to severe: 36.7%, 309/842). For Italian respondents, the percentages of overall weight loss and moderate-to-severe weight loss were 85.1% (109/128) and 70.3% (90/128), respectively. Only 35.0% (295/842) of all respondents reported having their weight measured regularly during treatment; 45.7% (385/842) believed their physician considered cancer-related weight loss unimportant. Respondents [all: 56.9% (472/830); Italian: 73.0% (92/126); Spanish: 68.9% (42/61); Greek: 79.7% (47/59)] were unaware of supplements' negative effects during therapy or the need to inform their physician about these supplements [all: 43.6% (362/830); Italian: 55.6% (70/126); Spanish: 47.5% (29/61); Greek: 49.2% (29/59)]. The term 'cachexia' was generally unknown to respondents [all: 72.9% (603/827); Italian: 64.3% (81/126); Spanish: 68.9% (42/61); Greek: 47.5% (28/59)] and most respondents [all: 92.4% (764/827); Italian: 91.3% (115/126); Spanish: 91.8% (56/61); Greek: 86.4% (51/59)] received no cachexia-related information.

CONCLUSIONS

Patients reported differences in perspective between them and physicians on cancer-related nutritional issues and the specific nutritional approaches available for cancer treatment. Increasing physician focus on nutrition during treatment, particularly among Italian physicians, and providing information on optimizing nutrition to patients are essential factors to improving patients' quality of life.

Prevalence and Consequences of Preoperative Weight Loss in Gynecologic Surgery

Preoperative malnutrition and weight loss negatively impact postoperative outcomes in various surgical fields. However, for gynecologic surgery, evidence is still scarce, especially if surgery is performed within enhanced recovery after surgery (ERAS) pathways. This study aimed to assess the prevalence and impact of preoperative weight loss in patients undergoing major gynecologic procedures within a standardized ERAS pathway between October 2013 and January 2017. Out of 339 consecutive patients, 33 (10%) presented significant unintentional preoperative weight loss of more than 5% during the 6 months preceding surgery. These patients were less compliant to the ERAS protocol (>70% of all items: 70% vs. 94%, p < 0.001) presented more postoperative overall complications (15/33 (45%) vs. 69/306 (22.5%), p = 0.009), and had an increased length of hospital stay (5 ± 4 days vs. 3 ± 2 days, p = 0.011). While patients experiencing weight loss underwent more extensive surgical procedures, after multivariate analysis, weight loss ≥5% was retained as an independent risk factor for postoperative complications (OR 2.44; 95% CI 1.00-5.95), and after considering several surrogates for extensive surgery including significant blood loss (OR 2.23; 95% CI 1.15-4.31) as confounders. The results of this study suggest that systematic nutritional screening in ERAS pathways should be implemented.

Malnutrition in patients who underwent surgery for spinal metastases

Background

Malnutrition is common among cancer patients and has been associated with increased morbidity and mortality. The primary objective of this study was to evaluate the nutritional status of patients who underwent surgical treatment for spinal metastases. In addition, the association between nutritional status and length of stay, health related quality of life (HRQOL), the occurrence of adverse events and survival was investigated.

Methods

A single center prospective observational cohort study including patients with spinal metastases who underwent surgical treatment was performed. Demographic, diagnostic, treatment, and HRQOL (SOSGOQ2.0 and EQ-5D-3L) data were prospectively collected at baseline and 12 weeks post-treatment. Nutritional status was evaluated with the Patient-Generated Subjective Global Assessment (PG-SGA).

Results

A total of 39 patients were included. Malnutrition as determined by the PG-SGA was present in 36 (92%) of the patients, of whom 32 (82%) were moderately malnourished and 4 (10%) were severely malnourished. Malnourishment was associated with lower baseline SOSGOQ2.0 total scores, SOSGOQ2.0 physical function, mental health and social functioning scores, EQ-5D total scores and EQ-5D mobility scores. No association between malnutrition and survival could be determined.

Conclusions

The prevalence of malnutrition among surgically treated patients with spinal metastases is high. Malnutrition demonstrated to be associated with lower baseline HRQOL scores. Future larger studies are needed to further investigate the prognostic significance of malnutrition.

Combination of apatinib and continuous nutritional support for a gastric cancer patient with brain metastasis prolongs survival

WHAT IS KNOWN AND OBJECTIVES

Gastric cancer is the most common gastrointestinal malignant tumour in China, which rarely metastasizes into the central nervous system. However, brain metastasis leads to increased risk of death.

CASE SUMMARY

Here, we report a case of brain metastasis from gastric cancer, which was treated with apatinib and continual nutritional support, with a survival time of 2 years.

WHAT IS NEW AND CONCLUSION

The combination of apatinib and continual nutritional support may be an option for the treatment of brain metastasis from gastric cancer. A prospective study should be performed to confirm this.

Clinical Value of Nutritional Status in Cancer: What is its Impact and how it Affects Disease Progression and Prognosis?

Malnutrition is a common finding in cancer patients, which can affect disease progression and survival. This review aims to critically summarize the prognostic role of nutritional status, from Body Mass Index (BMI) and weight loss to nutrition screening tools and biochemical indices, in cancer patients. According to the currently available data, Prognostic Nutritional Index (PNI) was a significant prognostic factor of patients' survival, both in univariate and multivariate analyses. Pre-operative albumin was also correlated with worse outcomes, being an independent prognostic factor of survival in several studies. BMI was also well-studied, with contradictory results. Although, lower BMI was found to be an independent prognostic factor of shorter survival in some studies, in others it did not have an impact on survival. In this aspect, this review highlights the significant prognostic role of nutritional status in the disease progression and survival of cancer patients. Further, good-quality prospective studies are needed in order to draw precise conclusions on the prognostic role of specific nutritional assessment tools, and biochemical indices associated with the nutritional status in more cancer types, such as liver, breast and prostate cancer, and hematological malignancies.

The prognostic value of the preoperative c-reactive protein/albumin ratio in ovarian cancer

Background

Inflammation plays an important role in the pathogenesis of ovarian cancer. This study sought to investigate the association between the preoperative c-reactive protein/albumin ratio (CRP/Alb) and oncological outcomes in ovarian cancer patients.

Methods

Two hundred patients with histologically verified ovarian cancer between June 2006 and July 2012 were retrospectively reviewed. Overall survival was evaluated by the Kaplan–Meier method and log-rank test. The significance of risk factors for overall survival was evaluated with the Cox proportional hazards model. Additionally, area under the receiver operating characteristic curve (AUC) was used to compare the predictive ability of CRP/Alb, Glasgow Prognostic Score (GPS), modified GPS (mGPS), neutrophil lymphocyte ratio (NLR), platelet lymphocyte ratio (PLR), prognostic index (PI) and prognostic nutritional index (PNI).

Results

The optimal cutoff value of CRP/Alb was 0.68. Increased CRP/Alb (≥0.68) was associated with advanced stage, residual tumor, ascites, elevated serum carbohydrate antigen(CA)-125 level, GPS, and mGPS (all p < 0.05). Patients with high CRP/Alb had poor overall survival compared to those with low CRP/Alb (p < 0.001). Multivariable analysis showed that CRP/Alb (Hazard Ratio (HR) 1.330, 95% confidence interval (CI) 1.131–1.564, p = 0.001), tumor stage (HR 1.577, 95% CI 1.189–2.091, p = 0.002), residual tumor (HR 2.337, 95% CI 1.518–3.597, p < 0.001) and age (HR 1.017, 95% CI 1.000–1.035, p = 0.046) were independent prognostic factors for overall survival. Additionally, the CRP/Alb showed greater AUC values at 1 year (0.692), 3 years (0.659), and 5 years (0.682) than GPS, mGPS and PNI.

Conclusions

The CRP/Alb is a novel independent marker of poor prognosis among ovarian cancer patients and shows superior prognostic ability compared to the established inflammation-based prognostic indices.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-017-3220-x) contains supplementary material, which is available to authorized users.

Association of nutritional status-related indices and chemotherapy-induced adverse events in gastric cancer patients

Background

Malnutrition in gastrectomized patients receiving chemotherapy is associated with the susceptibility to chemotherapy-related adverse events. This study evaluated pre-operative nutritional status-related indices associated with adverse events in post-operation gastric cancer patients receiving chemotherapy.

Methods

Medical records of 234 gastrectomized patients under adjuvant tegafur/gimeracil/oteracil chemotherapy with extended lymph node dissection were analyzed. Nutritional status assessment included Patient-Generated Subjective Global Assessment (PG-SGA), body weight, body mass index, serum albumin concentration, and Nutrition Risk Index (NRI). Chemotherapy-originated adverse events were determined using Common Terminology Criteria for Adverse Events.

Results

PG-SGA indicated 59% of the patients were malnourished, and 27.8% of the patients revealed serious malnutrition with PG-SGA score of ≥9. Fifteen % of patients lost ≥10% of the initial body weight, 14.5% of the patients had hypoalbuminemia (<3.5 g/dL), and 66.2% had NRI score less than 97.5 indicating moderate to severe malnutrition. Hematological adverse events were present in 94% (≥grade 1) and 16.2% (≥grade 3). Non-hematological adverse events occurred in 95.7% (≥grade1) and 16.7% (≥grade 3) of the patients. PG-SGA and NRI score was not associated with treatment-induced adverse events. Multivariate analyses indicated that female, low body mass index, and hypoalbuminemia were independent risk factors for grade 3/4 hematological adverse events. Age was an independent risk factor for grade 3/4 non-hematological adverse events. Neutropenia was the most frequently occurring adverse event, and associated risk factors were female, total gastrectomy, and hypoalbuminemia.

Conclusions

Hypoalbuminemia, not PG-SGA or NRI may predict chemotherapy-induced adverse events in gastrectomized cancer patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-016-2934-5) contains supplementary material, which is available to authorized users.

Malnutrition Identified by the Nutritional Risk Index and Poor Prognosis in Advanced Epithelial Ovarian Carcinoma

Ovarian cancer is a chronic disease with a risk of malnutrition. Nutritional Risk Index (NRI) has been reported as a simple and accurate tool to assess the nutritional status. We sought to explore the prevalence of malnutrition and its association with survival in ovarian cancer. A retrospective study was conducted in 213 advanced ovarian cancer patients. NRI was calculated before and at the end of treatment using patients' body weight and serum albumin level. Overall survival (OS) and progression-free survival (PFS) were estimated by Kaplan-Meier method, and associations were assessed using a Cox proportional hazards analysis adjusted for known prognostic variables. Moderate to severely malnourished patients had lower 5-yr OS (45.3%) compared to normal to mild group (64.0%), respectively (P = 0.024). Adjusted for covariates, the relative risk of death was 5.8 times higher in moderate/severely malnourished group identified at the last course of chemotherapy (HR = 5.896, 95% CI = 2.723-12.764, P < 0.001). Similarly, this cohort had shorter PFS compared with normal to mild risk group (median 15 vs. 28 months, P = 0.011). Malnutrition is prevalent among ovarian cancer patients and is found to be a significant predictor for mortality.

Nutrition support and dietary interventions for patients with lung cancer: current insights

Malnutrition and weight loss are prevalent in patients with lung cancer. The impact of malnutrition on patients with cancer, and specifically in patients with lung cancer, has been demonstrated in a large number of studies. Malnutrition has been shown to negatively affect treatment completion, survival, quality of life, physical function, and health care costs. Emerging evidence is providing some insight into which lung cancer patients are at higher nutritional risk. In lung cancer patients treated with radiotherapy, stage III or more disease, treatment with concurrent chemotherapy and the extent of radiotherapy delivered to the esophagus appear to confer a higher risk of weight loss during and post-treatment. Studies investigating nutrition interventions for lung cancer patients have examined intensive dietary counseling, supplementation with fish oils, and interdisciplinary models of nutrition and exercise interventions and show promise for improved outcomes from these interventions. However, further research utilizing these interventions in large clinical trials is required to definitively establish effective interventions in this patient group.

Cross-sectional study on comorbidities and adverse events in patients with advanced and recurrent ovarian cancer in France

Purpose

The purpose of this study was to evaluate the prevalence of comorbidities and adverse events (AEs), and determine the treatment patterns according to platinum-sensitivity status in patients with advanced (stage IIIB–IV) or recurrent epithelial ovarian cancer (EOC).

Methods

A cross-sectional study was carried out in France with patients over 18 years, diagnosed with advanced (stage IIIB–IV) or recurrent EOC between 2009 and 2012. A total of 23 physicians (oncologists and gynecologists) participated, contributing 127 patients. Data were abstracted by participating physicians into a case report form.

Results

Of the 127 patients included, 92 (72.4%) had advanced EOC and 35 (27.6%) had recurrent EOC. A total of 73 comorbidities were reported in 44 patients (34.6%). Vascular (10.2%), metabolic (7.1%), respiratory (5.5%), and psychiatric disorders (5.5%) were the most common types of comorbidities reported. Prevalence of AEs was 74.8%, of which 12.6% were classified as serious. The most common AEs were anemia (16.5%), hematologic events (12.6%), taste change (11.8%), and headache (7.1%). Throughout the follow-up period, twelve patient deaths were reported (six due to disease progression). Of 35 patients with recurrent disease, 16 were highly platinum sensitive (recurrence >12 months after stopping platinum-based therapy), eleven were partially platinum sensitive (recurrence 6–12 months after stopping platinum-based therapy), seven were platinum resistant (recurrence within 6 months of stopping platinum-based therapy or progression while receiving second- or later-line platinum-based therapy), and one was platinum refractory (recurrence within 6 months from the start of first-line platinum-based therapy).

Conclusion

In this cross-sectional study of advanced and metastatic ovarian cancer patients, approximately one-third of patients were diagnosed with comorbidities, and approximately three-quarters were diagnosed with AEs (12.6% with severe AEs).

Assessing the feasibility of a mobile health-supported clinical decision support system for nutritional triage in oncology outpatients using Arden Syntax

BACKGROUND

Nutritional screening procedures followed by regular nutrition monitoring for oncological outpatients are no standard practice in many European hospital wards and outpatient settings. As a result, early signs of malnutrition are missed and nutritional treatment is initiated when patients have already experienced severe weight loss.

OBJECTIVE

We report on a novel clinical decision support system (CDSS) for the global assessment and nutritional triage of the nutritional condition of oncology outpatients. The system combines clinical and laboratory data collected in the clinical setting with patient-generated data from a smartphone application for monitoring the patients' nutritional status. Our objective is to assess the feasibility of a CDSS that combines the aforementioned data sources and describe its integration into a hospital information system. Furthermore, we collected patients' opinions on the value of the system, and whether they would regard the system as a useful aid in coping with their condition.

MATERIALS AND METHODS

The system implements the Patient-Generated Subjective Global Assessment (PG-SGA) to monitor nutritional status in the outpatient setting. A smartphone application is used to collect patient-generated data by performing weekly mini-surveys on patients concerning their eating habits, weight, and overall well-being. Data are uploaded on completion of each mini-survey and stored on a secure server at the Medical University of Vienna (MUV). The data are then combined with relevant clinical information from the Vienna General Hospital (VGH) information system. The knowledge base for the CDSS is implemented in medical logic modules (MLMs) using Arden Syntax. A three-month pilot clinical trial was performed to test the feasibility of the system. Qualitative questionnaires were used to obtain the patients' opinions on the usability and personal value of the system during the four-week test period.

RESULTS

We used the existing separation between the scientific and clinical data domains in the secured network environment (SNE) at the MUV and VGH to our advantage by importing, storing, and processing both patient-generated and routine data in the scientific data domain. To limit exposure to the SNE, patient-generated data stored outside the SNE were imported to the scientific domain once a day. The CDSS created for nutritional assessment and triage comprised ten MLMs, each including either a sub-assessment or the final results of the PG-SGA. Finally, an interface created for the hospital information system showed the results directly in clinical routine. In all 22 patients completed the clinical study. The results of the questionnaires showed that 91% of the patients were generally happy with the usability of the system, 91% believed that the application was of additional value in detecting cancer-related malnutrition, and 82% found it helpful as a long-term monitoring tool.

DISCUSSION AND CONCLUSION

Despite strict protection of the clinical data domain, a CDSS employing patient-generated data can be integrated into clinical routine. The CDSS discussed in this report combined the information entered into a smartphone application with clinical data in order to inform the physician of a patient's nutritional status and thus permit suitable and timely intervention. The initial results show that the smartphone application was well accepted by patients, who considered it useful, but not many oncological outpatients were willing to participate in the clinical study because they did not possess an Android phone or lacked smartphone expertise. Furthermore, the results indicate that patient-generated data could be employed to augment clinical data and calculate metrics such as the PG-SGA without excessive effort by using a secure intermediate location as the locus of data storage and processing.

Dietary habits changes and quality of life in patients undergoing chemotherapy for epithelial ovarian cancer

PURPOSE

The aim of this study was to evaluate dietary habit changes in patients undergoing chemotherapy for epithelial ovarian cancer.

METHODS

Sixty one patients undergoing chemotherapy for epithelial ovarian cancer were enrolled to the study and 44 completed. The dietary intake was evaluated by 7-day food records, and the changes in dietary intake and food-preparing methods were estimated based on a 101-item semiquantitative food frequency questionnaire. Nutritional status was checked with the use of body weight and height, waist and hip circumferences, skinfolds and subjective global assessment tool. Quality of life was measured with the use of EORTC QLQ-C30 and EORTC QLQ-OV28.

RESULTS

Despite high average body mass index (BMI) (26.7-28.0 kg/m(2)), malnutrition risk was observed in 43.7 and 10.7 % of patients receiving first-line and subsequent-line chemotherapy, respectively (p < 0.001). Dietary intake and quality of life did not differ between the studied groups. A lot of dietary habits changes were observed. Women undergoing subsequent-line chemotherapy consumed more frequently rye bread, pasta, buttermilk, vegetable, fruit, oils, nuts, and juices. Women undergoing first-line chemotherapy consumed more milk, cottage cheese, cream, eggs, fish and seafood, meat offal, salty snacks, and jam. Additionally, women undergoing subsequent-line chemotherapy more often applied cooking in water (p < 0.0001) and baking (p < 0.05).

CONCLUSIONS

Women undergoing chemotherapy for ovarian cancer change their dietary habits in a pro healthy direction, and these changes are more expressed in patients undergoing subsequent-line chemotherapy.

A longitudinal study investigating quality of life and nutritional outcomes in advanced cancer patients receiving home parenteral nutrition

Background

In cancer patients where gastrointestinal function is marginal and malnutrition significant enough to result in the requirement for intensive nutrition support, parenteral nutrition (PN) is indicated. This longitudinal study examined the quality of life (QoL) and nutritional outcomes in advanced cancer patients receiving home PN (HPN).

Methods

Fifty-two adult cancer patients (21 males, 31 females, average age 53 years) treated at a specialized cancer facility between April 2009 and November 2011 met criteria. QoL and nutritional status were measured at baseline and every month while on HPN using EORTC-QLQ-C30, Karnofsky Performance Status (KPS), and Subjective Global Assessment (SGA). Repeated measures ANOVA and Generalized Estimating Equations (GEE) were used to evaluate longitudinal changes in QoL and SGA.

Results

Cancer diagnoses included pancreatic (n = 14), colorectal (n = 11), ovarian (n = 6), appendix (n = 5), stomach (n = 4) and others (n = 12). Average weight loss 6-months prior to HPN was 13.2 kg (16.9%). Average weight at initiation of HPN was 62.2 kg. In patients with available follow-up data after 1 month (n = 39), there was a significant improvement in SGA, weight (61.5 to 63.1 kg; p = 0.03) and KPS (61.6 to 67.3; p = 0.01) from baseline. Similarly, after 2 months (n = 22), there was an improvement in global QoL (37.1 to 49.2; p = 0.02), SGA, weight (57.6 to 60 kg; p = 0.04) and KPS (63.2 to 73.2; p = 0.01) from baseline. Finally, after 3 months (n = 15), there was an improvement in global QoL (30.6 to 54.4; p = 0.02), SGA, weight (61.1 to 65.9 kg; p = 0.04) and KPS (64.0 to 78.7; p = 0.002) from baseline. Upon GEE analysis, every 1 month of HPN was associated with an increase of 6.3 points in global QoL (p<0.001), 1.3 kg in weight (p = 0.009) and 5.8 points in KPS (p<0.001).

Conclusions

HPN is associated with an improvement in QoL, KPS and nutritional status in advanced cancer patients, irrespective of their tumor type, who have compromised enteral intake and malnutrition. The greatest benefit was seen in patients with 3 months of HPN, although patients receiving HPN for 1 or 2 months also demonstrated significant improvements.

The relationship between nutritional status, inflammatory markers and survival in patients with advanced cancer: a prospective cohort study

BACKGROUND

Malnutrition and elevated inflammatory markers have a negative impact on clinical outcomes in cancer patients. Few studies have investigated the associations between inflammatory makers, nutritional status and survival. This study investigates the association between nutritional status, inflammatory markers and overall survival (OS) in patients with advanced cancer.

METHODS

This prospective cohort study recruited 114 adult patients from January 2007 to January 2010. It included patients diagnosed with advanced cancer, good Eastern Cooperative Oncology Group (ECOG) performance status 0-2, a prognosis of more than 3 months and had not received chemotherapy for advanced cancer prior to enrollment. Baseline data were collected prior to commencement of chemotherapy. Patients were followed up from the date of baseline nutritional assessment until the date of death or the date that data were last updated, whichever came first.

RESULTS

Malnourished cancer patients had statistically significant higher concentrations of serum C-reactive protein (CRP), neutrophil-to-lymphocyte ratio (NLR) or modified Glasgow Prognostic Score (mGPS) prior to starting chemotherapy. In univariate analyses to predict survival, mGPS 1 or 2 had a hazard ratio (HR) of 1.81 (95 % confidence interval (CI) 1.13-2.89) and NLR ≥ 5 had a HR of 1.13 (95 % CI 1.08-4.60) and malnutrition (HR of 1.66 for Patient-Generated Subjective Global Assessment (PG-SGA) B (95 % CI 1.02-2.71), and HR for severely malnourished patients (PG-SGA C) was 2.73 (95 % CI 1.50-4.96).

CONCLUSIONS

Inflammatory markers were statistically associated with malnutrition. Malnutrition and mGPS were significant independent predictors of overall survival in patients with advanced cancer.

A Pre-post Evaluation of an Ambulatory Nutrition Support Service for Malnourished Patients Post Hospital Discharge: A Pilot Study

Introduction: Malnutrition is common among hospitalised patients, with poor follow up of nutrition support post-discharge. Published studies on the efficacy of ambulatory nutrition support (ANS) for malnourished patients post-discharge are scarce. The aims of this study were to evaluate the rate of dietetics follow-up of malnourished patients post discharge, before (2008) and after (2010) implementation of a new ANS service, and to evaluate nutritional outcomes post-implementation. Materials and Methods: Consecutive samples of 261 (2008) and 163 (2010) adult inpatients referred to dietetics and assessed as malnourished using Subjective Global Assessment (SGA) were enrolled. All subjects received inpatient nutrition intervention and dietetic outpatient clinic follow-up appointments. For the 2010 cohort, ANS was initiated to provide telephone follow-up and home visits for patients who failed to attend the outpatient clinic. Subjective Global Assessment, body weight, quality of life (EQ-5D VAS) and handgrip strength were measured at baseline and five months post-discharge. Paired t-test was used to compare pre- and post-intervention results. Results: In 2008, only 15% of patients returned for follow-up with a dietitian within four months post-discharge. After implementation of ANS in 2010, the follow-up rate was 100%. Mean weight improved from 44.0 ± 8.5 kg to 46.3 ± 9.6 kg, EQ-5D VAS from 61.2 ± 19.8 to 71.6 ± 17.4 and handgrip strength from 15.1 ± 7.1 kg force to 17.5 ± 8.5 kg force; P <0.001 for all. Seventy-four percent of patients improved in SGA score. Conclusion: Ambulatory nutrition support resulted in significant improvements in follow-up rate, nutritional status and quality of life of malnourished patients post-discharge. Key words: Home visit, Malnutrition, Outcomes, Telephone, 7-point Subjective Global Assessment