Attitudes of surgeons to the use of postoperative markers of the systemic inflammatory response following elective surgery

Background: Cancer is responsible for 7.6 million deaths worldwide and surgery is the primary modality of a curative outcome. Postoperative care is of considerable importance and it is against this backdrop that a questionnaire based study assessing the attitudes of surgeons to monitoring postoperative systemic inflammation was carried out. Method: A Web based survey including 10 questions on the “attitudes of surgeons to the use of postoperative markers of the systemic inflammatory response following elective surgery” was distributed via email. Two cohorts were approached to participate in the survey. Cohort 1 consisted of 1092 surgeons on the “Association of Coloproctology of Great Britain and Ireland (ACPGBI)” membership list. Cohort 2 consisted of 270 surgeons who had published in this field in the past as identified by two recent reviews. A reminder email was sent out 21 days after the initial email in both cases and the survey was closed after 42 days in both cases. Result: In total 29 surgeons (2.7%) from cohort 1 and 40 surgeons (14.8%) from cohort 2 responded to the survey. The majority of responders were from Europe (77%), were colorectal specialists (64%) and were consultants (84%) and worked in teaching hospitals (54%) and used minimally invasive techniques (87%). The majority of responders measured CRP routinely in the post-operative period (85%) and used CRP to guide their decision making (91%) and believed that CRP monitoring should be incorporated into postoperative guidelines (81%). Conclusion: Although there was a limited response the majority of surgeons surveyed measure the systemic inflammatory response following elective surgery and use CRP measurements together with clinical findings to guide postoperative care. The present results provide a baseline against which future surveys can be compared

How and why systemic inflammation worsens quality of life in patients with advanced cancer

Introduction: The presence of an innate host systemic inflammatory response has been reported to be a negative prognostic factor in a wide group of solid tumour types in both the operable and advanced setting, both local and distant. In addition, this host systemic inflammatory response is associated with both clinician reported patient performance status and self-reported measures of quality of life in patients with cancer. Areas covered: A variety of mechanisms are thought to underlie this, including the influence of the host immune response on physical symptoms such as pain and fatigue, its effect on organ systems associated with physical ability and well being such as skeletal muscle, and bone marrow. Furthermore, this innate inflammatory response is thought to have a direct negative impact on mood through its action on the central nervous system. Expert commentary: It is clear that the host systemic inflammatory response represents a target for intervention in terms of both improving quality of life and prognosis in patients with advanced cancer. Based on this paradigm, future research should focus both on pathways which might be targeted by novel agents, but also on whether existing anti-inflammatory drugs might be of benefit

The relationship between imaging-based body composition analysis and the systemic inflammatory response in patients with cancer: a systematic review

Background and aim: Cancer is the second leading cause of death globally. Nutritional status (cachexia) and systemic inflammation play a significant role in predicting cancer outcome. The aim of the present review was to examine the relationship between imaging-based body composition and systemic inflammation in patients with cancer. Methods: MEDLINE, EMBASE, Cochrane Library and Google Scholar were searched up to 31 March 2019 for published articles using MESH terms cancer, body composition, systemic inflammation, Dual energy X-ray absorptiometry (DEXA), magnetic resonance imaging (MRI), ultrasound sonography (USS) and computed tomography (CT). Studies performed in adult patients with cancer describing the relationship between imaging-based body composition and measures of the systemic inflammatory response were included in this review. Results: The literature search retrieved 807 studies and 23 met the final eligibility criteria and consisted of prospective and retrospective cohort studies comprising 11,474 patients. CT was the most common imaging modality used (20 studies) and primary operable (16 studies) and colorectal cancer (10 studies) were the most commonly studied cancers. Low skeletal muscle index (SMI) and systemic inflammation were consistently associated; both had a prognostic value and this relationship between low SMI and systemic inflammation was confirmed in four longitudinal studies. There was also evidence that skeletal muscle density (SMD) and systemic inflammation were associated (9 studies). Discussion: The majority of studies examining the relationship between CT based body composition and systemic inflammation were in primary operable diseases and in patients with colorectal cancer. These studies showed that there was a consistent association between low skeletal muscle mass and the presence of a systemic inflammatory response. These findings have important implications for the definition of cancer cachexia and its treatment

The relationship between systemic inflammation, body composition and clinical outcomes in patients with operable colorectal cancer at low and medium to high nutritional risk

Background: In accordance with European Society of Parenteral and Enteral Nutrition guidelines, the combination of malnutrition universal screening tool (MUST), systemic inflammation [modified Glasgow prognostic score (mGPS)] and body composition [skeletal muscle index (SMI) and skeletal muscle density (SMD)] were examined in relation to clinical outcomes in patients undergoing surgery for colorectal cancer (CRC). Methods: Data were collected for stages I–III CRC patients from prospectively maintained data base at the academic department of surgery, Glasgow Royal Infirmary. From the initial sample of 1046, pre‐admission MUST score was available in 984 patients. The classification into low malnutrition risk (MUST = 0, n = 810) and moderate to high malnutrition risk (MUST 1 to ≥2, n = 174) groups and their relationship to systemic inflammatory response and body composition (SMI and SMD) with clinical outcomes were examined using univariate and multivariate analyses. Results: Compared with those patients at low nutrition risk (MUST = 0), patients at moderate to high malnutrition risk (MUST 1 to ≥2) had an elevated mGPS (P < 0.001), neutrophil lymphocyte ratio (NLR) (P < 0.001), low SMI (P ≤ 0.001) and low SMD (P = 0.015). MUST was an important prognostic factor for length of hospital stay (P < 0.001) and 3 years overall survival (P < 0.001). In low malnutrition risk patients (MUST = 0), those who were systemically inflammed (mGPS 1/2, n = 187), had an elevated NLR (P < 0.001), low SMI (P < 0.001), low SMD (P < 0.01), increased post‐operative complications (P < 0.05), longer hospital stay >7 days (P < 0.001), and poorer 3 years survival (P < 0.05) compared with those who were not systemically inflamed. On multivariate analysis, American Society of Anaesthesiologist (ASA) score (P < 0.05) and mGPS (P < 0.05) were independently associated with increased risk of clinical complications. ASA, mGPS, and NLR were independently associated with prolonged hospital stay (P < 0.05, P < 0.05, and P < 0.001, respectively). ASA, tumour, node, metastasis stage, and mGPS were independently associated with overall survival (P < 0.01, P < 0.001, and P < 0.05, respectively). In medium‐risk to high‐risk patients (MUST = 1/2), those who were systemically inflamed (mGPS 1/2, n = 75) had higher ASA (P < 0.05), elevated NLR (P < 0.01), low SMI (P = 0.05) and low SMD (P < 0.05), increased length of hospital stay (P < 0.05), and poorer 3 years survival (P < 0.01), compared with those who were not systemically inflamed. Conclusions: A small proportion of patients with primary operable CRC was at nutrition risk as defined by MUST alone in both low risk nutrition patients and medium/high risk nutrition patients. The systemic inflammatory response was associated with lower SMI, lower SMD, and poor clinical outcomes. The systemic inflammatory response is an important measure in the nutritional assessment of patients undergoing surgery for CRC

Hypoalbuminemia reflects nutritional risk, body composition and systemic inflammation and is independently associated with survival in patients with colorectal cancer

It has long been recognized that albumin has prognostic value in patients with cancer. However, although the Global Leadership Initiative on Malnutrition GLIM criteria (based on five diagnostic criteria, three phenotypic criteria and two etiologic criteria) recognize inflammation as an important etiologic factor in malnutrition, there are limited data regarding the association between albumin, nutritional risk, body composition and systemic inflammation, and whether albumin is associated with mortality independent of these parameters. The aim of this study was to examine the relationship between albumin, nutritional risk, body composition, systemic inflammation, and outcomes in patients with colorectal cancer (CRC). A retrospective cohort study (n = 795) was carried out in which patients were divided into normal and hypoalbuminaemic groups (albumin  <35 g/L) in the presence and absence of a systemic inflammatory response C-reactive protein (CRP >10 and <10 mg/L, respectively). Post-operative complications, severity of complications and mortality were considered as outcome measures. Categorical variables were analyzed using Chi-square test χ 2or linear-by-linear association. Survival data were analyzed using univariate and multivariate Cox regression. In the presence of a systemic inflammatory response, hypoalbuminemia was directly associated with Malnutrition Universal Screening Tool MUST (p < 0.001) and inversely associated with Body Mass Index BMI (p < 0.001), subcutaneous adiposity (p < 0.01), visceral obesity (p < 0.01), skeletal muscle index (p < 0.001) and skeletal muscle density (p < 0.001). There was no significant association between hypoalbuminemia and either the presence of complications or their severity. In the absence of a systemic inflammatory response (n = 589), hypoalbuminemia was directly associated with MUST (p < 0.05) and inversely associated with BMI (p < 0.01), subcutaneous adiposity (p < 0.05), visceral adiposity (p < 0.05), skeletal muscle index (p < 0.01) and skeletal muscle density (p < 0.001). Hypoalbuminemia was, independently of inflammatory markers, associated with poorer cancer-specific and overall survival (both p < 0.001). The results suggest that hypoalbuminemia in patients with CRC reflects both increased nutritional risk and greater systemic inflammatory response and was independently associated with poorer survival in patients with CRC

Variation in the management of elderly patients in two neighboring breast units is due to preferences and attitudes of health professionals

Introduction: Elderly breast cancer patients have been shown to be managed less aggressively than younger patients. There is evidence that their management varies between institutions. We audited the management of elderly patients in two neighboring units in Glasgow and aimed to identify reasons for any differences in practice found. Methods: Patients aged ≥70 years, who were managed for a new diagnosis of breast cancer in the two units between 2009 and 2013, were identified from a prospectively maintained database. Tumor pathology, treatment details, postcode and consultant in charge of care were obtained from the same database. Comorbidities were obtained from each patient’s electronic clinical record. Questionnaires were distributed to members of each multidisciplinary teams. Results: 487 elderly patients in Unit 1 and 467 in Unit 2 were identified. 76.2% patients in Unit 1 were managed surgically compared to 63.7% in Unit 2 (p<0.0001). There was no difference between the two units in patient age, tumor pathology, deprivation or comorbidity. 16.2% patients managed surgically in Unit 1 had a comorbidity score of 6 and above compared to 11% of surgically managed patients in Unit 2 (p=0.036). Responses to questionnaires suggested that staff at Unit 1 were more confident of the safety of general anesthetic in elderly patients and were more willing to consider local anesthetic procedures. Conclusion: A higher proportion of patients aged >70 years with breast cancer were managed surgically in Unit 1 compared to Unit 2. Reasons for variation in practice seem to be related to attitudes of medical professionals toward surgery in the elderly, rather than patient or pathological factors

The role of the systemic inflammatory response in predicting outcomes in patients with operable cancer: Systematic review and meta-analysis

Cancer remains a leading causes of death worldwide and an elevated systemic inflammatory response (SIR) is associated with reduced survival in patients with operable cancer. This review aims to examine the evidence for the role of systemic inflammation based prognostic scores in patients with operable cancers. A wide-ranging literature review using targeted medical subject headings for human studies in English was carried out in the MEDLINE, EMBASE, and CDSR databases until the end of 2016. The SIR has independent prognostic value, across tumour types and geographical locations. In particular neutrophil lymphocyte ratio (NLR) (n = 158), platelet lymphocyte ratio (PLR) (n = 68), lymphocyte monocyte ratio (LMR) (n = 21) and Glasgow Prognostic Score/ modified Glasgow Prognostic Score (GPS/mGPS) (n = 60) were consistently validated. On meta-analysis there was a significant relationship between elevated NLR and overall survival (OS) (p < 0.00001)/ cancer specific survival (CSS) (p < 0.00001), between elevated LMR and OS (p < 0.00001)/CSS (p < 0.00001), and elevated PLR and OS (p < 0.00001)/CSS (p = 0.005). There was also a significant relationship between elevated GPS/mGPS and OS (p < 0.00001)/CSS (p < 0.00001). These results consolidate the prognostic value of the NLR, PLR, LMR and GPS/mGPS in patients with resectable cancers. This is particularly true for the NLR/GPS/mGPS which should form part of the routine preoperative and postoperative workup

Comparison of the prognostic value of ECOG-PS, MGPS and BMI/WL: Implications for a clinically important framework in the assessment and treatment of advanced cancer

BACKGROUND AND AIMS:The systemic inflammatory response is associated with the loss of lean tissue, anorexia, weakness, fatigue and reduced survival in patients with advanced cancer and therefore is important in the definition of cancer cachexia. The aim of the present study was to carry out a direct comparison of the prognostic value of Eastern Cooperative Oncology Group Performance Status (ECOG-PS), modified Glasgow Prognostic Score (mGPS) and Body Mass Index/Weight Loss Grade (BMI/WL grade) in patients with advanced cancer. METHOD:All data were collected prospectively across 18 sites in the UK and Ireland. Patient's age, sex, ECOG-PS, mGPS and BMI/WL grade were recorded, as were details of underlying disease including metastases. Survival data were analysed using univariate and multivariate Cox regression. RESULTS:A total of 730 patients were assessed. The majority of patients were male (53%), over 65 years of age (56%), had an ECOG-PS>0/1 (56%), mGPS≥1 (56%), BMI≥25 (51%), <2.5% weight loss (57%) and had metastatic disease (86%). On multivariate cox regression analysis ECOG-PS (HR 1.61 95%CI 1.42-1.83, p < 0.001), mGPS (HR 1.53, 95%CI 1.39-1.69, p < 0.001) and BMI/WL grade (HR 1.41, 95%CI 1.25-1.60, p < 0.001) remained independently associated with overall survival. In patients with a BMI/WL grade 0/1 both ECOG and mGPS remained independently associated with overall survival. CONCLUSION:The ECOG/mGPS framework may form the basis of risk stratification of survival in patients with advanced cancer

The relationship between computed tomography‐derived body composition and survival in colorectal cancer: the effect of image software

Background: In the literature, there is considerable variation of the proportion of patients reported as having a low skeletal muscle index (SMI) (sarcopenia) or skeletal muscle radiodensity (SMD) (myosteatosis). The aim of the present study was to compare two commonly used software packages, one manual and one semi‐automated to quantify body composition of patients with colorectal cancer. Methods: The study included 341 patients with colorectal cancer. ImageJ and Slice‐O‐Matic were used to quantify the computed tomography images for total fat index, visceral obesity (visceral fat index, VFI), high subcutaneous fat index (SFI), sarcopenia (SMI), and myosteatosis (SMD). Bland–Altman analysis was conducted to test agreement of the two software programs for these indices. Survival analysis was carried out using previously defined thresholds and Cox regression. Results: In Bland–Altman analysis, ImageJ gave consistently higher values for all body composition parameters (P < 0.001), resulting in more patients classified as high SFI (P < 0.001) and high VFI (P < 0.001) and fewer patients being classified as low SMI (P < 0.0001) and SMD (P < 0.001). The difference between SFI calculated using ImageJ and Slice‐O‐Matic was +7.9%. The difference between VFI, calculated using ImageJ and Slice‐O‐Matic, was +20.3%. The difference between low SMI and SMDs, estimated using ImageJ and Slice‐O‐Matic, was +2.9% and +1.2%, respectively. SFI, VFI, SMI (Dolan), SMD (Dolan), SMI (Martin), and SMD (Martin) were significantly associated with shorter overall survival using ImageJ (all P < 0.05). Conclusions: ImageJ when compared with Slice‐O‐Matic gave higher values of different body composition parameters, and this impacted on the number of patients classified according to defined thresholds and their relationship with survival