PhilSPEN Online Journal of Parenteral and Enteral Nutrition

(Article 134 | POJ_0126)

Original Clinical Investigation

Association of the Nutritional Status with One-year Survival Rate of Cancer Patients seen at an Out-Patient Nutrition Clinic in a Private Tertiary Hospital: A Two-year Retrospective Cohort Study

Abstract | Introduction | Methodology | Results | Discussion | Conclusion | References | Back to Total Name and Codes page2

Submitted: | Posted:

Authors:

    1. Francis Gail M. Turalba, MD; Clinical Nutrition Service, St. Luke's Medical Center, Quezon City, Philippines
    2. Luisito O. Llido, MD; Clinical Nutrition Service, St. Luke’s Medical Center, Quezon City, Philippines
    Corresponding Author: Dr. Francis Gail M. Turalba

Institution where research was conducted:

Clinical Nutrition Sevice, St. Luke’s Medical Center, E. Rodriguez Avenue, Quezon City, Metro-Manila, Philippines

 

ABSTRACT: | Back

Background:

Cancer patients are at risk for malnutrition which directly affects their clinical outcomes. Nutrition upbuilding of cancer patients is important for them to be able to tolerate cancer treatment. Hence, there is a need to strengthen nutrition care management and compliance to nutrition interventions in all institutions treating cancer patients, commencing even in the out-patient setting, to improve patient outcomes and survival.

Objective:

To determine the association of the nutritional status and profile of cancer patients with one-year survival rate.

Methodology:

This is a two-year retrospective cohort study wherein chart reviews of 104 cancer patients were done. 87 patients had data on living status (dead or alive) after 1 year from first out-patient nutrition consult. Statistical analyses were used to associate one-year survival rate with the following nutrition parameters: Body Mass Index (BMI), presence of poor appetite and weight loss, initial calorie and protein intake, initial calorie intake compared to Total Caloric Requirement (TCR), initial protein intake compared to Total Protein Requirement (TPR), timing of nutrition support, and compliance to nutrition intervention based on adequacy of intake on first follow-up.

Results:

BMI, presence of poor appetite and weight loss, initial calorie and protein intake, initial calorie intake compared to TCR, and timing of nutrition support had no significant association to survival. In the univariate analysis, adequacy of calorie intake on first follow-up (p=0.04), and compliance to nutrition intervention based on adequacy of intake on first follow-up (p=0.05) showed a significant association with one-year survival rate of cancer patients.  In the multivariate analysis using logistic regression, both initial protein intake compared to TPR (OR=6.46; 95% CI=0.99 – 40.23; p=0.05)  and compliance to nutrition intervention based on adequacy of calorie and protein intake on first follow-up (OR=5.45; 95% CI=0.99 – 31.10; p=0.05) were found to be significantly associated to survival.

Conclusion:

In this study, nutritional status based on BMI showed no significant association with one-year survival rate. Considering other nutrition parameters, there is a higher chance for survival of cancer patients with initial protein intake that is equal or more than the TPR compared with initial protein intake less than the TPR. There is also a higher chance for survival of cancer patients with adequate calorie and protein intake on their first out-patient follow-up than those with inadequate intake of calories and protein.

KEYWORDS: Cancer, Malnutrition, Nutrition, Adequacy of Intake, Calories, Protein, Survival Rate

 

INTRODUCTION | Back

According to the World Health Organization, cancer is a leading cause of death worldwide, accounting for 8.8 million deaths in 20151. Cancer patients present with several risk factors for malnutrition, which directly impacts on their outcome2. Nutritional decline is often accepted as part of the cancer course and its treatment3. But even if cancer-related malnutrition is evident, it remains under-recognized. Data from the Cancer Institute of St. Luke’s Medical Center showed that 2527 and 2500 cancer patients were seen at the social service out-patient department in the year 2016 and 2017, respectively. However, not all cancer patients were referred to the Clinical Nutrition Service for nutrition evaluation.

Although several reports and studies have stated the importance of nutrition support in the treatment of cancer patients2-4, not all cancer patients in the Philippines are routinely referred for nutritional assessment and intervention prior to or during the course of cancer treatment. Even the practice of seeking alternative treatment prior to receiving standard care for cancer, not only delays appropriate treatment but has contributed to the worsening nutritional status of cancer patients.

This study was conducted to describe the profile of cancer patients seen at an out-patient nutrition clinic and to determine the association of nutrition parameters to their survival. Results of this study could support the establishment of programs that will strengthen nutrition care management at the start of cancer diagnosis commencing in the out-patient setting.

METHODOLOGY | Back

Study Design and Population

This is a retrospective cohort study which included all patients diagnosed with any type of cancer, 19 years old and above, seen at the out-patient Nutrition clinic of St. Luke’s Medical Center – Quezon City, a private tertiary hospital, from March 1, 2016 to March 31, 2018.  Excluded from the study were cancer patients with incomplete data and unknown status of survival after one year (whether the patient died or survived).

Study Procedure

A list of all cancer patients seen from March 1, 2016 until March 31, 2018 at the out-patient Nutrition Clinic was obtained from the Clinical Nutrition out-patient logbook.  The out-patient charts of all patients diagnosed with cancer within the time period were retrieved from the OPD medical records office.   
Chart reviews of all cancer patients seen at the out-patient Nutrition Clinic were done.  The charts reviewed were patients referred to the out-patient Nutrition Clinic who were seen and evaluated by Clinical Nutrition Physician Fellows and well-trained Clinical Dietitians. The following baseline data were obtained: (1) Age, Gender, and Socioeconomic Status, (2) Weight and height, (3) Type of Cancer and Tumor Stage, (4) Cancer treatment upon referral, (5) Route of Feeding, (6) Initial Calorie and Protein Intake, and (7) Number of Follow-ups.  Additional data such as computed Body Mass Index (based on the WHO classification), timing of Nutrition Support, intake of Oral Nutrition Supplements (ONS), along with other nutrition parameters mentioned in the specific objectives were also recorded in the data collection form (see Appendix A).
The survival or mortality of the cancer patients up to 1 year after the initial consult at the out-patient Nutrition Clinic were documented by reviewing the electronic medical records and digital charts of the patients. For those cancer patients with no available information found in the medical records on survival (whether dead or alive), their living status was extensively searched in the records of the Social Service office. The registered phone numbers of the patients were also contacted and living status of the patients, including date of death, were confirmed and established with whomever answered the phone.  The flowchart of methodology is seen in Figure 1.


 

Operational definitions

  1. Total Caloric Requirement (TCR): computed calorie needs of an individual based on weight17
  2. Total Protein Requirement (TPR): computed protein needs of an individual based on weight17
  3. Adequacy of Calorie or Protein Intake: computed actual calorie or protein intake of the patient divided by the TCR or TPR multiplied by 100. Intake is adequate when it is greater than or equal to 75 percent19
  4. Initial Calorie and Protein Intake: computed calorie and protein intake based on usual food intake or 24-hour food recall done during first out-patient consult. 
  5. Timing of Nutrition Support: phase of cancer treatment when nutrition consult was done and nutrition prescription was given.
  6. Nutritional Status: determined by Body Mass Index20

Outcome Measure

The outcome of the study isOne-year Survival Rate which is defined as the percentage of cancer patients included in the study who were still alive one year after initial consult at the out-patient Nutrition Clinic. One-year survival rate (S) was computed using the direct method, calculated as follows:

S =    ____A____   x 100        
            T
in which: A = number of cancer patients alive after 1 year
               T = number of cancer patients seen

Sample Size Estimation
Sample size was calculated based on the comparison of mortality rate among cancer patients who are underweight versus cancer patients in the general population.  Assuming that mortality rate among cancer patients for the general population is 9.4 percent 21, and mortality rate of underweight patients is hypothesized to be 22%, with an alpha error of 5 percent, power of 80% and a one-tailed alternative hypothesis, sample size calculated was 102 per group or 204 for two groups.  Controlling for 2 more variables (age and cancer type) in the analysis with an additional 20% for each control variable, final sample size required was 384.  However, since this is a retrospective cohort study, the number of patients included were limited to only those patients who were referred to the out-patient Nutrition Clinic seen from March 1, 2016 to March 31, 2018.

Data Analysis
Determination of the association between the nutritional profile and clinical outcomes were analyzed using Univariate and Multivariate statistics.  Chi-square test was used for qualitative independent variables and logistic regression for quantitative variables.  Odds ratio and the 95% Confidence Interval were also calculated.  Multiple logistic regression was then utilized.  Level of significance was set at alpha=0.05.

 a.  The clinical protocol and all relevant documents were reviewed and approved by the SLMC Institutional Ethics Review Committee.
 b.  Patient confidentiality was respected by ensuring anonymity of patients’ records and number codes were assigned to each patient.
c.   All study data were recorded and the investigators were responsible for the integrity of the data. 
d.  The manner of disseminating and communicating the study results guaranteed the protection of the confidentiality of patient’s data. There was no direct benefit or harm to patients expected from this study.
e.  Raw data, data collection sheets, and other documents will be kept in a locked container for 2 years from the time the research paper has been completed in which only the investigators have access to. 

RESULTS | Back

A total of 104 patients were included in the study with more females (56.7%) than males (43.3%). The mean age of males and females were 56 and 55 years old, respectively. Table 1 shows the comparison of the demographic profile of cancer patients according to gender. There was a significant difference noted in the proportion of males and females according to socio-economic status. Significantly higher proportion of males were employed than females with 16 (35.6%) and 11 (18.6%) respectively (p=0.05). There was also a significant difference noted in the weight and height according to gender. Both weight and height were significantly higher among males (p<0.001). Most patients seen had normal BMI (n=47, 45.2%), followed by underweight (n=42, 40.4%), overweight (n=14, 13.5%), and Obese (n=1, 1.0 %) but there was no significant difference in BMI between gender. In terms of the presence of comorbities, there was a higher number of females compared to males with no comorbities (n= 31 vs. 28, p=0.32), with diabetes (n= 13 vs. 6, p=0.26), and with hypertension (n= 10 vs. 9, p=0.69), but there was no significant difference. On initial consult, the presence of poor appetite was seen in 54 patients (51.9%, p=0.18) and weight loss was apparent in 71 patients (68.3%, p=0.76).

Moreover, there was a significant difference noted in the proportion of males and females according to type of cancer. A significantly higher proportion of males had head and neck cancer than females with 27 (60.0%) and 18 (30.5%) respectively (p=0.002). Similarly, a higher proportion of males was noted to have thoracic cancer with 4 (8.9%) and none among females (p=0.03). There was a statistically significant difference in the number of patients with gastrointestinal cancer 27 (45.8%) and 11 (24.4%) for females and males respectively (p=0.02). Naturally, gynecologic cancer was significantly higher among females than males (p=0.03), since this type of cancer only occurs in females. 

As for the tumor stage, males 80% (n=36) had locoregional cancer while 20% (n=9) had advanced cancer. There were more females with locoregional cancer (n=52, 88.1%) compared to those with advanced cancer (n=7, 11.9%).  In total, there were more cancer patients with locoregional cancer 88 (84.6%) compared to those with advanced cancer 16 (15.4%) but this was not statistically significant.   Majority of patients had no cancer treatment upon referral (n=44, 42.3%).  But there were 40 patients (38.5%) who already underwent surgery, 9 patients (8.7%) who had chemotherapy, 7 patients (6.7%) who had chemotherapy plus radiotherapy but with no statistical difference. 

For route of feeding upon referral, most patients were on oral diet with intake of oral nutrition supplements (n=44, 42.%), followed by oral intake alone (n=33, 31.7%), tube feeding (n=22, 21.2%), oral plus tube feeding (n=4, 3.8%), and parenteral nutrition (n=1, 1%) but with no statistical difference.  Upon referral, majority of patient’s calorie intake was within the range of 1001 kcal to 2000 kcal per day (n=63, 60.6%) and protein intake was less than 70 grams or less than 1 g/kg/day (n=87, 83.7%) but with no statistical difference.  42.7% of patients did not return for out-patient follow-up.  There were 16 patients (15.5%) who had one follow-up, 18 patients (17.5%) with 2 follow-ups, and 25 patients (24.3%) who had greater than or equal to 3 follow- ups but all with no statistical difference. 

Table 1. Comparison of the Demographic and Clinical Profile of Cancer Patients seen at an Out-Patient Nutrition Clinic by Gender

 

Male
(n=45)

Female
(n=59)

Total
(n=104)

P value

Age (in years)
Mean ± SD

56.11 ± 13.25

55.39 ± 13.10

55.70 ± 13.10

0.78

Socioeconomic Status

Employed
Unemployed

 

16 (35.6%)
29 (64.4%)

 

11 (18.6%)
48 (81.4%)

 

27 (26.0%)
77 (74.0%)

 

0.05
0.05

Weight (kg)
Mean ± SD

54.66 ± 11.58

46.46 ± 11.03

50.01 ± 11.94

<0.001

Height (m)
Mean ± SD

1.64 ± 0.06

1.52 ± 0.05

1.58 ± 0.08

<0.001

BMI Classification
Underweight
Normal
Overweight
Obese

 

16 (35.6%)
22 (48.9%)
  7 (15.6%)

 

26 (44.1%)
25 (42.4%)
  7 (11.9%)
  1 (  1.7%)

 

42 (40.4%)
47 (45.2%)
14 (13.5%)
  1 ( 1.0%)

 

0.38
0.51
0.58
1.00 §

Comorbidities
Hypertension
Diabetes
Chronic Kidney Disease
None

 

9 (20.0%)
6 (13.3%)
1 (  2.2%)
28 (62.2%) 

 

10 (52.6%)
13 (22.4%)
0
31 (52.5%)

 

19 (18.3%)
19 (18.4%)
  1 ( 1.0%)
59 (56.7%)

 

0.69
0.26
0.43 §
0.32

Poor Appetite
Yes
No

 

20 (44.4%)
25 (55.6%)

 

34 (57.6%)
25 (42.4%)

 

54 (51.9%)
50 (48.1%)

 

0.18
0.18

Presence of Weight Loss
With weight loss
Without weight loss

 

30 (66.7%)
15 (33.3%)

 

41 (69.5%)
18 (30.5%)

 

71 (68.3%)
33 (31.7%)

 

0.76
0.76

Type of Cancer
Head and Neck
Thoracic
Gastrointestinal
Gynecologic
Hematologic
Genitourinary
Neurologic
Soft Tissue
Breast
Neuroendocrine

 

27 (60.0%)
  4 ( 8.9%)
11 (24.4%)
0
0
 2 ( 4.4%)
0
0
0
  1 ( 2.2%)

 

18 (30.5%)
0
27 (45.8%)
  6 (10.2%)
  1 ( 1.7%)
  1 ( 1.7%)
  1 ( 1.7%)
  1 ( 1.7%)
  4 ( 6.8%)
0

 

45 (43.3%)
  4 ( 3.8%)
38 (36.5%)
  6 ( 5.8%)
  1 ( 1.0%)
  3 ( 2.9%)
  1 ( 1.0%)
  1 ( 1.0%)
  4 ( 3.8%)
  1 ( 1.0%)

 

0.002
0.03 §
0.02  ‡
0.03 §
1.00 §
0.58 §
1.00 §
1.00 §
0.13 §
0.43 §

Tumor Stage
Locoregional
Advanced

 

36 (80.0%)
  9 (20.0%)

 

52 (88.1%)
  7 (11.9%)

 

88 (84.6%)
16 (15.4%)

 

0.25
0.25

Cancer Treatment upon referral
None
Chemotherapy
Radiotherapy
Chemotherapy and Radiotherapy
Surgery
Chemotherapy and Surgery
Radiotherapy and Surgery
Chemotherapy, Radiotherapy & Surgery

 

19 (42.2%)
  4 ( 8.9%)
  1 ( 2.2%)
  4 ( 8.9%)
14 (31.1%)
  1 ( 2.2%)
  1 ( 2.2%)
  1 ( 2.2%)

 

25 (42.4%)
  5 (  8.5%)
0
  3 (  5.1%)
26 (44.1%)
0
0
0

 

44 (42.3%)
  9 ( 8.7%)
  1 ( 1.0%)
  7 ( 6.7%)
40 (38.5%)
  1 ( 1.0%)
  1 ( 1.0%)
  1 ( 1.0%)

 

0.99
1.00 §
0.44 §
0.69
0.44
0.44 §
0.44 §
0.44 §

Route of Feeding upon referral
Oral
Oral plus ONS
Tube feeding
Oral and tube feeding
Parenteral Nutrition
Oral and Parenteral Nutrition

 

 

14 (31.1%)
17 (37.8%)
11 (24.4%)
  3 ( 6.7%)
0
0

 

19 (32.2%)
27 (45.8%)
11 (18.6%)
  1 ( 1.7%)
  1 ( 1.7%)
0

 

33 (31.7%)
44 (42.3%)
22 (21.2%)
  4 ( 3.8%)
  1 ( 1.0%)
0

 

0.91
0.41
0.52
0.21 §
1.00 §
---

Calorie Intake Upon Referral
<500 kcal per day
500 – 1000 kcal per day
1001 – 2000 kcal per day
>2000 kcal per day

 

3 (  6.7%)
13 (28.9%)
28 (62.2%)
  1 (  2.2%)

 

0
20 (33.9%)
35 (59.3%)
  4 (  6.8%)

 

  3 (  2.9%)
33 (31.7%)
63 (60.6%)
  5 (  4.8%)

 

0.08 §
0.58
0.76
0.39 §

Protein Intake Upon Referral*
<70 grams per day <(1g/kg/day)
70 – 140 grams per day (1.2 – 2g/kg/day)

 

39 (86.7%)
  6 (13.3%)

 

48 (81.4%)
11 (18.6%)

 

87 (83.7%)
17 (16.4%)

 

0.47
0.47

Number of Follow-ups
0
1
2
>/= 3

 

19 (43.2%)
  6 (13.6%)
  5 (11.4%)
14 (31.8%)

 

25 (42.4%)
10 (16.9%)
13 (22.0%)
11 (18.6%)

 

44 (42.7%)
16 (15.5%)
18 (17.5%)
25 (24.3%)

 

0.99
0.69
0.26
0.31

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Based on a 70 kilogram person
p>0.05- Not significant; p ≤0.05-Significant         
T-test; Chi-square test; §Fisher Exact test; ׀׀ T- test

Of the 104 patients, only 87 patients had data on living status (dead or alive) after 1 year. Among them,sixty-four (73.6%) survived after one year. Table 2 shows that the study population had no statistically significant difference when associating gender, type and stage of cancer with one-year survival rate of cancer patients seen at an out-patient Nutrition Clinic.  Among cancer patients who survived, there were more females 37 (75.5%) compared to males 27 (71.1%) p= 0.64. For patients with head and neck cancer, 80% (n=28) survived while 62.5% (n=20) of patients with gastrointestinal cancer survived. 56 (75.7%) out of 74 patients with locoregional cancer survived while 8 (61.5%) out of 13 patients with advanced cancer survived (p=0.32).

Table 2. Association of Gender, Type of Cancer and Tumor Stage with One-Year Survival Rate of Cancer Patients seen at an Out-patient Nutrition Clinic
 
One year survival rate
   
 
Died (n=23)
Alive (n=64)
Total (n=87)
P value

Gender
Male
Female

11 (28.9%)
12 (24.5%)

27 (71.1%)
37 (75.5%)

38
49

0.64
0.64

Type of Cancer
Head and Neck
Thoracic
Gastrointestinal
Gynecologic
Hematologic
Genitourinary
Neurologic
Soft Tissue
Breast
Neuroendocrine

 

7 (20%)
2 (50%)
12 (37.5%)
0
1 (100%)
0
0
0
1
0

 

28 (80%)
2 (50%)
20(62.5%)
5 (100%)
0
3 (100%)
1 (100%)
1 (100%)
3 (75%)
1 (100%)

 

35
4
32
5
1
3
1
1
4
1

 

0.26
0.28 §
0.07
0.32 §
0.26 §
0.56 §
1.00 §
1.00 §
1.00 §
1.00 §

Tumor Stage
Locoregional
Advanced

18 (24.3%)
5 (38.5%)

56 (75.7%)
8 (61.5%)

74
13

0.32 §
0.32 §

 

p>0.05- Not significant; p ≤0.05-Significant, T-test; Chi-square test; §Fisher Exact test; ׀׀ T- test

Table 3 shows the association of the nutritional profile with one-year survival rate of cancer patients. Across the different BMI classifications, survival of cancer patients were as follows: 72.2% of underweight patients (n=26), 69.4% with normal BMI (n=25), 85.7% of overweight patients (n=12), and 100% of obese patients (n=1), but there was no statistical significance.  More patients reported that they didn’t have poor appetite 34 (77.3%) but had weight loss 46 (75.4%) and initial intake of calories 58 (73.4%) and protein 59 (76.6%) were less than the computed calorie and protein goals, respectively.  On first out- patient follow-up, there was significantly more patients who consumed adequate calories (n=33, 82.5%, p=0.04). There were also more patients who consumed adequate proteins 20 (87.0%) but not statistically significant (p=0.10). There was note of more cancer patients (n=27, 73.0%, p=0.55) who were alive after 1 year when nutrition support commenced during cancer treatment as compared to patients given nutrition support pre-treatment (n=23, 79.3%, p=0.55). BMI, presence of poor appetite (p=0.43) and weight loss (p=0.55) prior to consult, and timing of nutrition support (p=0.55) associated with one-year survival rate showed no significant difference. 

Table 3. Association of the Nutritional Profile with One-Year Survival Rate of Cancer Patients seen at an Out-patient Nutrition Clinic

 

 

One-year Survival
Rate

Total
(n=87)

P value

Died
(n=23)

Alive
(n=64)

BMI Classification

Underweight (<18.5 kg/m2)
Normal (18.5-24.9 kg/m2)
Overweight (25-29.9 kg/m2)
Obese (>30kg/m2)

 

10 (27.8%)
11 (30.6%)
  2 (14.3%
0

 

26 (72.2%)
25 (69.4%)
12 (85.7%)
  1 (100%)

 

36
36
14
1

 

0.81
0.46
0.34 §
1.00 §

Poor Appetite

Yes
No

 

13 (30.2%)
10 (22.7%)

 

30 (69.8%)
34 (77.3%)

 

43
44

 

0.43
0.43

Presence of Weight Loss

With weight loss
Without weight loss

 

15 (24.6%)
  8 (30.8%)

 

46 (75.4%)
18 (69.2%)

 

61
26

 

0.55
0.55

Initial Calorie Intake

<500 kcal per day
500 – 1000 kcal per day
1001 – 2000 kcal per day
>2000 kcal per day

 

0
  8 (28.6%)
14 (27.5%)
  1 (20.0%)

 

  3 (100%)
20 (71.4%)
37 (72.5%)
  4 (80.0%)

 

  3
28
51
  5

 

0.56 §
0.75
0.80
1.00 §

Initial Calorie Intake Compared to TCR
Less than computed target goals
More than computed goals

 

21 (26.6%)
  2 (25.0%)

 

58 (73.4%)
  6 (75.0%)

 

79
8

 

1.00
1.00

Initial Protein Intake*
<70 grams per day <(1g/kg/day)
70 – 140 grams per day (1.2 – 2g/kg/day)

 

18 (24.0%)
  5 (41.7%)

 

57 (76.0%)
  7 (58.3%)

 

75
12

 

0.27
0.27

Initial Protein Intake Compared to TPR
Less than computed target goals
Equal to computed target goals
More than computed goals

 

18 (23.4%)
  3 (50.0%)
  2 (50.0%)

 

59 (76.6%)
  3 (50.0%)
  2 (50.0%)

 

77
  6
  4

 

0.12 §
0.16 §
0.26 §

Timing of Nutrition Support
Pre-treatment
During treatment

(n=16)
  6 (20.7%)
10 (27.0%)

(n=50)
23 (79.3%)
27 (73.0%)

(n=66)
29
37

 

0.55
0.55

Adequacy of Calories Intake on First Follow-up
Adequate
Inadequate

(n=11)
7 (17.5%)
4 (57.1%)

(n=36)
33 (82.5%)
  3 (42.9%)

(n=47)
40
 7

 

0.04 §
0.04§

Adequacy of Protein Intake on First Follow-up
Adequate
Inadequate

(n=11)
3 (13.0%)
8 (33.3%)

(n=36)
20 (87.0%)
16 (66.7%)

(n=47)
23
24

 

0.10
0.10

Compliance to Nutrition Intervention Based on Adequacy of Intake on First Follow-up
Adequate calories and protein
Adequate calories and inadequate protein
Inadequate calories and adequate protein
Inadequate calories and protein

 

(n=11)

3 (13.0%)
4 (23.5%)
0
4 (57.1%)

 

(n=36)

20 (87.0%)
13 (76.5%)
0
  3 (42.9%)

 

(n=47)

23
17
0
7

 

 

0.04
0.17
---
0.04

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Based on a 70 kilogram person
p>0.05- Not significant; p ≤0.05-Significant  
     T-test; Chi-square test; §Fisher Exact test; ׀׀ T- test

In the multivariate analysis using logistic regression, both initial protein intake compared to TPR (with equal or more than the TPR) and compliance to nutrition intervention based on adequacy of calorie and protein intake on first follow-up were found to be significantly associated to survival. There is a higher chance for patients with initial protein intake equal or more than the TPR for survival than those with initial protein intake less than the TPR (OR=6.46; 95% CI=0.99 – 40.23; p=0.05). Moreover, there is a higher chance for patients with intake of adequate calories and protein for survival than those with inadequate calorie and protein intake(OR=5.45; 95% CI=0.99 – 31.10; p=0.05) (Table 3).

 

Table 3. Multivariate Analysis on the Nutrition Parameters Associated with One-Year Survival Rate of Cancer Patients by Logistic Regression Analysis

Variable

OR

95% CI

P value

Initial protein intake compared to TPR (equal or more than computed TPR)

6.46

0.99 – 40.23

0.05

Compliance to nutrition intervention based on adequacy of intake on first follow-up (adequate calories and protein)

5.45

0.99 – 31.10

0.05

 

DISCUSSION: | Back

Among cancer patients seen at an out-patient nutrition clinic, the one-year survival rate is 73.6% which is comparable to the one-year cancer survival rate of 70.6% reported by the Kingston Clinical Commissioning Group (CCG) working to improve cancer outcomes in England22.  Results of this study showed that upon first consult at the out-patient nutrition clinic, 40.4% of cancer patients were underweight, 51.9% had poor appetite and 68.3% had weight loss.  In the PreMio Study, 51.1% of patients had nutritional impairment, including risk of malnutrition and overt malnutrition, with 53% of patients without metastases already with weight loss and 41% of patients with poor appetite present in at the first oncology visit14.  Poor appetite and presence of weight loss are parameters in nutrition screening used to identify patients who are nutritionally-at-risk despite normal body mass index. 

Considering the BMI of the cancer patients, there was no significant difference in survival after 1 year among cancer patients who were underweight, with normal BMI, overweight, and obese. Previous studies suggested that cancer patients with a lower BMI have more aggressive disease and cachexia, leading to a poor tolerance to chemotherapy and subsequent disease progression23-24 and that loss of muscle mass and BMI predict survival independently of conventional prognostic factors25.  In a study done by Dahlberg et.al (2013), results showed that high BMI is associated with significant survival26.   However in this study, nutritional status based on BMI showed no significant association with one-year survival rate.  Although BMI has been given value in predicting health risks and outcomes, it doesn’t represent the variability in body composition such as low muscle mass which is a powerful predictor of morbidity and mortality27.  BMI is frequently used to determine the nutritional status and prognosis of patients, particularly in the cancer and surgical populations15, using it alone to diagnose malnutrition is insufficient to identify those patients who are truly at risk.  Regardless of Body Mass Index (BMI), it is skeletal muscle depletion which is considered as a meaningful prognostic factor in patients with cancer. The loss of lean body mass has been associated with higher incidence of chemotherapy toxicity, shorter time to tumor progression, poorer surgical outcome, physical impairment and shorter survival15.

The highest frequency of malnutrition or undernutrition seen among cancer types were seen in patients with gastroesophageal, pancreatic, head and neck, and lung tumors14.  Although not statistically significant, results of this study showed that 80% of the patients with head and neck cancer and 62.5% with gastrointestinal cancer survived after 1 year.  75.7% of patients with locoregional cancer survived after 1 year from initial consult.  Tolentino et.al (2007), recommended in their study that initial nutrition screening and assessment should be done on all patients especially those with malignancy of the gastrointestinal tract and once these patients are identified to be nutritionally at risk, there should be aggressive provision of adequate enteral access (either surgical or percutaneous) 28.

Although no significant difference was seen in most baseline data between gender and also between some nutrition parameters with one-year survival rate, which may be due to the limited sample size, survival of the cancer patients in this study may be attributed to the following: (1) majority of the patients had no comorbidities, (2) nutrition support commenced during treatment, (3) most patients used oral nutrition supplements on top of oral diet, and (4)  majority of patients were compliant to nutrition intervention consuming adequate calories and protein. However, these variables in relation to survival should be further investigated in randomized controlled trials. 

Optimal nutritional status of cancer patients should be maintained for them to be able to tolerate and complete cancer treatment regimens for better survival.  Provision of nutrition support plays a role in improving dietary intake and nutrient delivery.  In a randomized trial on individualized nutrition intervention done by Ravasco et.al (2003), it was reported that patients with a poorer dietary intake, worse nutritional status, and poorer Quality of Life scores at the end of radiotherapy, had a significantly shorter median survival and an increased incidence of late radiotherapy-induced toxicity4.  Moreover, in a study done by Kondrup et al (2001), dietary intake was used as a criterion for treatment failure wherein the intake of less than 75% of estimated requirement caused no weight gain and even contributed to weight loss.  It was suggested that in patients who cannot be weighed, or who have edema, recording of food intake is important for monitoring improvement19.  Hence, adequate dietary intake consuming greater than or equal to 75 percent of total caloric and protein requirements should be achieved at all times.

Findings of this study significantly showed an association between consumption of adequate calories noted during the patients’ first follow-up with their one-year survival.  Most cancer patients in this study consumed more calories compared to protein probably because protein sources are more expensive.  It was noted that there was a significant difference in socioeconomic status of the patients which may have influenced their ability to procure protein-rich foods.

This study provided evidence that initial protein intake compared to TPR (consuming equal or more than the TPR) and compliance to nutrition intervention based on adequacy of calorie and protein intake on first follow-up were found to be significantly associated to survival after 1 year from first consult. This is supported by a study done by Manueles et.al, which showed that adequate intake of calories and protein in ICU patients results to improved survival29.  If we extrapolate results, knowing that if our cancer patients have initial protein intake equal or greater than the TPR and if they have adequate calories and protein intake noted on all out-patient follow-ups, then we may predict a higher chance for survival. 

This study was limited by the number of cancer patients who consulted at the out-patient nutrition clinic. The authors were unable to obtain a larger sample size due to the limited number of cancer patients being referred to the out-patient Nutrition Clinic in the previous years. The number of patients excluded in the study were due to no data on living status which is essential in computing the survival rate, hence these excluded subjects may have affected results of this study.  Body composition and physical activity were not determined in the out-patient Nutrition Clinic.

CONCLUSION: | Back

Among cancer patients seen at an out-patient nutrition clinic, nutritional status based on BMI showed no significant association with one-year survival rate. There is a higher chance for survival for cancer patients with initial protein intake equal or more than the TPR than those with initial protein intake less than the TPR. Considering compliance to nutrition intervention, there is a higher chance for survival of cancer patients with adequate calorie and protein intake on first out-patient follow-up than those with inadequate intake of calories and protein.

Since it is well documented that malnutrition adversely affects morbidity and mortality of cancer patients, it is important to screen and assess all cancer patients who will need appropriate and aggressive nutrition therapy prior to initiation of definitive cancer treatment. Rather than using BMI to determine nutritional status, other nutrition parameters such initial protein intake and adequacy of calorie and protein intake should be given importance.

Efforts on providing nutrition interventions that will help cancer patients reach their total protein requirements and achieve adequate calorie and protein intake should be strengthened. It is necessary that all patients diagnosed with cancer should be immediately referred to a Nutrition Support Team for early nutrition evaluation and treatment, commencing even in the out-patient setting, to improve patient outcomes and survival.

It is recommended that a prospective study or randomized controlled clinical trial, including more cancer patients, be done in order to attain better results.


 REFERENCES
: | Back

  1. World Health Organization. accessed August 23, 2018. https://www.wcrf.org/int/cancer-facts-figures/worldwide-data.
  2. Correia, M Isabel TD. Cancer-related Nutrition. s.l. : European Oncological Disease, 2007
  3. Capra, S, Ferguson, M, Ried, K. Cancer: Impact of Nutrition Intervention-Nutrition Issues for Patients. Nutrition, Volume 17, Issue 9, Pages 769-772. 2001
  4. Ravasco, P, Monteiro-Grillo, I, Vidal, PM, Camilo, ME. Impact of Nutrition on Outcome: A Prospective Randomized Controlled Trail in Patients with Head and Neck Cancer Undergoing Radiotherapy, Wiley InterScience. 2005
  5. Lochs H, Allison SP, Meier R, Pirlich M, Kondrup J, Schneider S, van den Berghe G, Pichard C. Introductory to the ESPEN guidelines on enteral nutrition: terminology, definitions and general topics, Clin Nutr., 25:180-186. 2006
  6. Argilés JM. Cancer-associated malnutrition. Eur J Oncol Nurs.;9 Suppl 2: S39-50. 2005
  7. Ottery, FD Cancer cachexia: prevention, early diagnosis, and management. Cancer Pract, Vols. Jul-Aug;2(4):263. 1994
  8. Marcel, C. Cancer Patients: Malnutrition and Interventions. Cinahl Information Systems, July 27, 2012.
  9. Aaldriks AA, van der Geest LG, Giltay EJ, et.al. Frailty and malnutrition predictive of mortality risk in older patients with advanced colorectal cancer receiving chemotherapy.. 4:218-226., J Geriatr Oncol. 2013.
  10. Maasberg S, Knappe-Drzikova B, Vonderbeck D, et.al. Malnutrition predicts clinical outcome in patients with neuroendocrine neoplasias. 104:11-25. Neuroendocrinology. 2017.
  11. Pressoir M, Desne S, Berchery D, Rossignol G, et.al.Prevalence, risk factors and clinical implications of malnutrition in French Comprehensive Cancer Centres. 102:966-971. Br J Cancer. 2010.
  12. Platek, ME, Johnson, J, Woolf, K, Makarem, N, Ompad, D. Availability of Outpatient Clinical Nutrition Services for Patients With Cancer Undergoing Treatment at Comprehensive Cancer Centers. New York. American Society of Clinical Oncology.2014
  13. Levin, R. Nutrition in the Patient with Lung Cancer. Chapter 8. Caring Ambassadors Program. 2014
  14. Muscaritoli, M, Lucia,S, Farcomeni,A, Lorusso,V et.al. Prevalence of malnutrition in patients at first medical oncology: the PreMiO study. 79884-79896, Oncotarget, Vols. Vol. 8, (No. 45),. 2017
  15. Aversa, Z, Costelli, P, Muscaritoli, M. Cancer-induced muscle wasting: latest findings in prevention and treatment. Ther Adv Med Oncol. Vol. 9(5) 369–382. 2017
  16. Ravasco P, Monteiro-Grillo I, Camilo ME. Does nutrition influence quality of life in cancer patients undergoing radiotherapy? Radiother Oncol , Vols. 67, 213–220. 2003
  17. Arends,J, Bachmann,P,Baracos,V, Barthelemy,N, Bertz,H et.al. ESPEN guidelines on nutrition in cancer patients. Clinical Nutrition published by Elsevier Ltd. 2016
  18. Trujillo,EB, et al. Closing the Gap in Nutrition Care at Outpatient Cancer Centers: Ongoing Initiatives of the Oncology Nutrition Dietetic Practice Group. Issue 4, Pages 749–760, JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS, Vols. Volume 118, April 2018
  19. Kondrup J. Can food intake in hospitals be improved. Clin Nutr., 20:153-160. 2001
  20. Gonzalez, MC,. Correia, MI, Heymsfield, SB. A requiem for BMI in the clinical setting. Current Opinion. Volume 20. Number 5. Wolters Kluwer Health. 2017
  21. Flegal KM, Graubard BI, Williamson DF, Gail MH. Cause‐specific excess deaths associated with underweight, overweight, and obesity. JAMA., Vols. 298: 2028‐2037. 2007Iggulden, P, Seager, S, Atkinson, S. Analysis of One year Cancer Survival Rates. NHS Kingston CCG Profile. 2016
  22. Pan C, He N, Zhao M et al. Subdividing the M1 stage of liver metastasis for nasopharyngeal carcinoma to better predict metastatic survival. 28: 1349–55, Med Oncol , 2011
  23. Li W, Shen LJ, Chen T et al. Overweight/obese status associates with favorable outcome in patients with metastatic nasopharyngeal carcinoma: A 10‐year retrospective study. 35 (1): 75. Chin J Cancer, 2016
  24. Martin L, Senesse P, Gioulbasanis I, Antoun S, Bozzetti, et.al. Diagnostic criteria for the classification of cancer-associated weight loss. J Clin Oncol., 33:90-99. 2015
  25. Dahlberg SE, Schiller JH, Bonomi PB et al. Body mass index and its association with clinical outcomes for advanced non‐small‐cell lung cancer patients enrolled on Eastern Cooperative Oncology Group clinical trials. 8: 1121–7. J Thorac Oncol , 2013
  26. Prado,C, Purcell, S, Alish,C,, Pereira, SL, Deutz,NE, Heyland, DK, Goodpaster, BH, Tappenden, KA, Heymsfield, SB. Implications of low muscle mass across the continuum of care: a narrative review. ANNALS OF MEDICINE. VOL. 50, NO. 8, 675–693. 2018
  27. Tolentino, R, Quizon,O, Llido, L. Nutritional status of patients with malignancy of the gastrointestinal tract and other malignancies – comparison of characteristics and pattern: a two year study in a private tertiary care hospital in the Philippines (years 2003-2004). 37-44., Philippine Journal of Oncology, December, Vol. 8. 2007
  28. Manaules, G, De Ramos, M, Sinamban, R, Llido, L.  Critical Care Nutrition- The effect of adequate calorie and protein intake on mortality, ventilator days, ICU and hospital stay: report from a private tertiary care hospital in the Philippines. PhilSPEN Online Journal. 2013
  29. Caccialanza, R,  Pedrazzoli, P, Cereda, E, Gavazzi, C, Pinto, C, Paccagnella, A, Beretta, GD, Nardi, M, Laviano, A, Zagonel, V. Nutritional Support in Cancer Patients: A Position Paper from the Italian Society of Medical Oncology (AIOM) and the Italian Society of Artificial Nutrition and Metabolism (SINPE). Journal of Cancer.Vol. 7. 2016

Abstract | Introduction | Methodology | Results | Discussion | References | Back to Total Name and Codes page2