Computed tomography diagnosed cachexia and sarcopenia in 725 oncology patients: is nutritional screening capturing hidden malnutrition?

Background: Nutrition screening on admission to hospital is mandated in many countries, but to date, there is no consensus on which tool is optimal in the oncology setting. Wasting conditions such as cancer cachexia (CC) and sarcopenia are common in cancer patients and negatively impact on outcomes; however, they are often masked by excessive adiposity. This study aimed to inform the application of screening in cancer populations by investigating whether commonly used nutritional screening tools are adequately capturing nutritionally vulnerable patients, including those with abnormal body composition phenotypes (CC, sarcopenia, and myosteatosis). Methods: A prospective study of ambulatory oncology outpatients presenting for chemotherapy was performed. A detailed survey incorporating clinical, nutritional, biochemical, and quality of life data was administered. Participants were screened for malnutrition using the Malnutrition Universal Screening Tool (MUST), Malnutrition Screening Tool (MST), and the Nutritional Risk Index (NRI). Computed tomography (CT) assessment of body composition was performed to diagnose CC, sarcopenia, and myosteatosis according to consensus criteria. Results: A total of 725 patients (60% male, median age 64 years) with solid tumours participated (45% metastatic disease). The majority were overweight/obese (57%). However, 67% were losing weight, and CT analysis revealed CC in 42%, sarcopenia in 41%, and myosteatosis in 46%. Among patients with CT-identified CC, the MUST, MST, and NRI tools categorized 27%, 35%, and 7% of them as ‘low nutritional risk’, respectively. The percentage of patients with CT-identified sarcopenia and myosteatosis that were categorised as ‘low nutritional risk’ by MUST, MST and NRI were 55%, 61%, and 14% and 52%, 50%, and 11%, respectively. Among these tools, the NRI was most sensitive, with scores <97.5 detecting 85.8%, 88.6%, and 92.9% of sarcopenia, myosteatosis, and CC cases, respectively. Using multivariate Cox proportional hazards models, NRI score < 97.5 predicted greater mortality risk (hazard ratio 1.8, confidence interval: 1.2–2.8, P = 0.007). Conclusions: High numbers of nutritionally vulnerable patients, with demonstrated abnormal body composition phenotypes on CT analysis, were misclassified by MUST and MST. Caution should be exercised when categorizing the nutritional risk of oncology patients using these tools. NRI detected the majority of abnormal body composition phenotypes and independently predicted survival. Of the tools examined, the NRI yielded the most valuable information from screening and demonstrated usefulness as an initial nutritional risk grading system in ambulatory oncology patients

The role of diet, nutritional assessment and nutritional intervention in the prevention of cancer and the treatment of cancer-related malnutrition

Nutrition plays a fundamental role in both the prevention and the treatment of cancer. The aim of this thesis was to describe the prevalence of malnutrition in the Irish oncology setting using gold standard methods of body composition analysis and to explore the identification and treatment of cancer-related malnutrition, as well as the role of nutrition in cancer prevention. Malnutrition was found to be highly prevalent in a cohort of oesophageal cancer patients undergoing minimally invasive oesophagectomy (MIO) (n=47). The procedure was associated with significant nutritional decline; however the implementation of an enhanced recovery after surgery protocol incorporating intensive peri-operative feeding appeared to yield significant clinical benefits, including shorter length of hospital stay, early cessation of muscle loss and restoration of quality of life in the early post-operative period. Malnutrition was also found to be prevalent in a cohort of Irish ambulatory oncology patients receiving chemotherapy (n=725), with excessive adiposity appearing to mask the muscle wasting and under-nutrition that was present. Malnutrition screening tools did not accurately detect the cohort of nutritionally vulnerable or malnourished patients that were captured by computed tomography analysis of body composition; however the Nutritional Risk Index screening tool demonstrated potential as it had a high sensitivity for abnormal body composition phenotypes and the ability to capture patients at risk of reduced survival. Following identification of malnutrition, it is essential that a targeted, multimodal nutritional intervention is implemented. No resource existed previously, that provided patients with understandable and reliable nutritional information to help attenuate the effects of cancer-induced weight loss. A 130-page, evidence-based resource containing 52 high-protein, high-calorie recipes was created to address this deficit, with 19 000 copies of this resource published and disseminated to over 75 sites nationally. The creation of an evidence-based resource focusing on the role of nutrition in the prevention of cancer was also commenced. The research undertaken in this thesis fulfilled a previously unmet need to quantify the level of malnutrition in the Irish oncology setting and to develop evidence-based practical resource to address cancer-related malnutrition and maximise on the potential preventability of cancer through dietary and lifestyle changes

Loss of skeletal muscle during systemic chemotherapy is prognostic of poor survival in patients with foregut cancer

Abstract Background Malnutrition, weight loss, and muscle wasting are common in patients with foregut cancers (oesophagus, stomach, pancreas, liver, and bile ducts) and are associated with adverse clinical outcomes. However, little is known about the changes in body composition that occur in these patients during chemotherapy and its impacts clinical outcomes. Patients and methods A prospective study of adult foregut cancer patients undergoing chemotherapy between 2012 and 2016 was conducted. Computed tomography images were evaluated for cross‐sectional skeletal muscle area (SMA) and adipose tissue area (ATA) at two time points [interval 118 days (IQR 92–58 days)]. Longitudinal changes in SMA and ATA were examined using paired t‐tests. Sarcopenia and low muscle attenuation (MA) were defined using published cut‐points. Cox proportional hazards models were used to estimate mortality hazard ratios for key predictors. Results A total of 225 foregut cancer patients were included (67% male, median age 66 years). At baseline, 40% were sarcopenic, 49% had low MA, and 62% had cancer cachexia. Longitudinal analysis (n = 163) revealed significant reductions in SMA [−6.1 cm2 (3.9%)/100 days, P 6.0%/100 days (highest fourth) independently predicted overall survival in patients receiving palliative chemotherapy [hazard ratio: 2.66, (95% CI: 1.42 to 4.97), P = 0.002]. Conclusions Patients with foregut cancers, particularly those treated with neoadjuvant chemotherapy, experience significant losses of muscle during chemotherapy. A high level of SMA loss is prognostic of reduced survival in patients treated with palliative chemotherapy. Multimodal interventions to stabilize or increase muscle mass and influence outcome warrant further investigation