Original articleNutritional status, cachexia and survival in patients with advanced colorectal carcinoma. Different assessment criteria for nutritional status provide unequal results
Introduction
Malnutrition and weight loss is a frequent problem in patients with malignant neoplastic disease, affecting prognosis, length of hospital stay, health-care costs, quality of life and survival.1 The prevalence of malnutrition varies among tumour types and sites, and the stage of the neoplastic disease. There is, however, also a variation between the criteria used for assessing malnutrition. In fact, screening for nutritional risk and referral for nutrition assessment are the fundamental first steps in the nutritional care pathway.2 Identification of patients at risk of malnutrition allows an appropriate nutritional assessment and nutritional intervention with the aim of improving clinical outcomes and quality of life.3 Nonetheless, there is no consensus on which method to use for assessing nutritional status in patients with malignant neoplastic diseases.
The European Society for Clinical Nutrition and Metabolism (ESPEN) guideline recommendation for nutrition screening in the hospital setting is the Nutritional Risk Screening (NRS-2002).4 NRS-2002 has not yet been validated in cohorts of patients with advanced malignant neoplastic disease. We previously reported that the Subjective Global Assessment (SGA) is a valid tool in assessing nutritional status in patients with advanced cancer5 and several studies have confirmed this finding.6, 7, 8, 9, 10
Recent interest in cancer cachexia has led to the development of new diagnostic tools to better understand this syndrome. It is understood that the pathophysiology of cachexia-related weight loss in cancer patients consists of a mixture of reduced food intake (undernutrition) and abnormal metabolism, leading to muscle degradation.11 Recently, the Cancer Cachexia Study Group (CCSG) suggested to apply three diagnostic criteria for cancer cachexia, (weight loss ≥10%, intake ≤1500 kcal/day, C-reactive protein (CRP) ≥10 mg/L), incorporating the sign of systemic inflammation related to the wasting process.12 Another distinct process mentioned in the current literature is the wasting of lean body mass, particularly the loss of skeletal muscle, indicating cachexia in cancer patients. Several studies have demonstrated the utility of computed tomography (CT) images for the assessment of skeletal muscle wasting in cancer patients, and its association with reduced survival.13, 14, 15 In a recently published review from the European Palliative Care Research Collaborative (EPCRC) concerning definition and classification of cancer cachexia, the incorporation of sarcopenia as a diagnostic criterion of cachexia together with weight loss and body mass index was suggested.16
At present, with the lack of consensus on which method to use for assessing nutritional status, an evaluation of nutritional screening and assessment tools is urgently needed. Thus, the aims of the present study were first and foremost to investigate the prevalence of patients identified to be nutritionally depleted by different nutritional assessment criteria in a cohort of patients with advanced colorectal carcinoma, and furthermore to examine whether the results obtained correlate with the patients' overall survival.
Section snippets
Patients
Fifty patients with stage IV colorectal cancer referred to the Department of Oncology, St. Olav's University Hospital, Trondheim, were invited to participate in a randomized study comparing dietary counselling to standard practice. Recruitment spanned from March, 2004 to June, 2006. Inclusion criteria were histopathologically or cytodiagnostically confirmed adenocarcinoma of the colon and rectum at stage IV. Patients too confused to fill in the questionnaires were excluded.
At the Cross Cancer
Results
The clinical data for all of the 77 patients are shown in Table 1a. There were 41 males and 36 females with a median age of 63 years (22–85). Only 12 patients went through preoperative radiotherapy. Most of the patients, 65 out of 77, had been through surgical interventions. Metastatic tumour load was mainly found in the liver and 50 out of 77 patients had metastases only to one site. Many patients showed a high performance status according to WHO, and some patients, 10 out of 77, presented
Discussion
Patients with malignant neoplastic diseases are considered at risk for sarcopenia, malnutrition, and cachexia. Owing to the lack of a clear-cut concept of the criteria defining these conditions in cancer patients, different nutritional assessment tools have been used. In the present study, the results obtained by means of these assessment tools in a relatively homogenous group of patients reveal a high degree of inconsistency in the classification of nutritional decline of individual patients.
Statement of authorship
Author's contributions to the manuscript are as follows: LT carried out the study and data analysis and drafted the manuscript. GF was responsible for recruitment of patients, data collection, samples and data analysis. SL contributed with statistical analysis and interpretation of the results. HU calculated energy intake and contributed with data analysis. VB contributed to the presentation of the results and writing of manuscript. CP was responsible for recruitment of patients, data
Conflict of interest
The authors have no conflict of interest to declare.
Acknowledgements
This work was performed at Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Norway and Department of Oncology, Division of Palliative Care Medicine, University of Alberta, Edmonton, Canada. The work was supported by grants from The Cancer Fund, St. Olavs Hospital, Trondheim University Hospital, the Medical Faculty at the Norwegian University of Science and Technology, the Canadian Institutes of Health Research, and from the Foundation of Clinical Cancer Research in
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