Nutritional status of patients with advanced cancer

Palliative Medicine 2002; 16: 33 ± 42

Nutritional status of patients with advanced cancer: the value of using the subjective global assessment of nutritional status as a screening tool Lene Thoresen Clinical dietitian, Irene Fjeldstad Registered nurse, Knut Krogstad Attending Physician, Palliative Medicine Unit, Oncology Clinic, University Hospital, Trondheim, Stein Kaasa Professor of Palliative Medicine, Chairman, Palliative Medicine Unit, Oncology Clinic, University Hospital, Trondheim, and Unit of Applied Clinical Research, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim and Ursula G. Falkmer Professor of Oncology, Chief Physician and Medical Director, Cancer Clinic, University Hospital, Trondheim and Faculty of Medicine, Norwegian University of Science and Technology Trondheim Abstract: In patients suffering from advanced neoplastic disease, malnutrition is a common complication affecting both the survival and quality of life. In order to monitor early dietary interventions, an assessment of patients’ nutritional status is essential. We assessed the nutritional status of 46 patients using two different methods: 1) an objective method of nutritional assessment and 2) the subjective global assessment (SGA) technique. It was found that 28 patients were characterized as malnourished by means of the objective method and 30 patients according to the SGA. The correlation of the results of the assessments between the two methods was high and a validation test of the SGA gave a sensitivity of 96% and specificity of 83%. The most frequent symptoms affecting food intake were anorexia, early satiety, dry mouth, pain and nausea. The results show that the SGA represents an easy method for assessment of the nutritional status in such cancer patients and that it can therefore be used as a screening tool. The high incidence of malnutrition in this group of patients, and their rare use of nutrient supplements, both indicate the importance of early nutritional assessment, and nutritional intervention when appropriate. Palliative Medicine 2002; 16: 33 ± 42 Key words: advanced neoplastic disease; anorexia; food intake; malnutrition; nutritional status; subjective global assessment Resume : La malnutrition est une complication freÂquente chez les patients souffrant de pathologie neÂoplasique eÂvolue e, affectant aÁ la fois la survie et la qualite de vie. Afin de pouvoir adapter de facË on preÂcoce leur reÂgime alimentaire, il est neÂcessaire de pratiquer une eÂvaluation du statut nutritionnel. Nous avons eÂvalue le statut nutritionnel de 46 patients aÁ l’aide de deux meÂthodes diffeÂrentes: 1° une meÂthode objective, 2° la technique d’eÂvaluation subjective globale (SGA). Il s’est ave re que d’apreÁ s la meÂthode objective 28 patients eÂtaient atteints de malnutrition contre 30 patients en utilisant la SGA. La correÂlation des reÂsultats des eÂvaluations entre les deux meÂthodes eÂtait eÂleveÂe et un test de validation du SGA a donne une sensibilite de 96% et une speÂcificite de 83%. Les principaux symptoà mes affectant la prise alimentaire eÂtaient l’anorexie, une satie te preÂcoce, une bouche seÁche, la douleur et les nause es. Les reÂsultats montrent que le SGA repreÂsente une meÂthode d’eÂvaluation simple du statut nutritionnel chez ces patients cance reux et de ce fait le SGA peut eÃtre utilise comme outil d’eÂvaluation. L’incidence eÂleve e de la malnutrition chez ces patients et l’utilisation peu freÂquente de supple ments nutritionnels indiquent l’importance d’une eÂvaluation nutritionnelle preÂcoce et une assistance nutritionnelle si besoin. Palliative Medicine 2002; 16: 33 ± 42 Mots - cle s: anorexie; cancer eÂvolue ; e valuation subjective globale; malnutrition; prise alimentaire; statut nutritionnel

Address for correspondence: Lene Thoresen, Palliative Medicine Unit, Department of Oncology, University Hospital, Trondheim N-7006, Norway. E-mail: [email protected] © Arnold 2002

10.1191/0269216302pm486oa

34 Lene Thoresen et al.

Introduction Malnutrition is common in patients with advanced neoplastic disease; between 50% and 90% of cancer patients lose weight, and about 40% lose more than 10% of their total body weight.1±3 Weight loss of greater than 10% is associated with an increased risk of morbidity and mortality, regardless of the underlying disease, and in cancer patients, weight loss is a negative prognostic factor.1,4±10 Indeed, it is generally assumed that up to 20 ± 50% of cancer deaths are related to malnutrition rather than to the disease itself.11±16 Quality of life is affected by both anorexia and loss of weight, the latter in that severe weight loss involves deterioration of muscle function with reduced physical function, altered body image and loss of control over body functions with increased need for care as a practical consequence.3,12 Both animal studies and clinical data12 suggest that malnutrition-induced loss of muscle mass and function may be irreversible in cancer patients. Assuming that prevention of further weight loss is likely to prevent complications, shorten hospitalization periods, decrease overall cost of care and preserve good quality of life, early detection of weight loss is an important task.4 Etiological factors leading to malnutrition may be divided into primary and secondary. Primary factors include hypermetabolism, metabolic abnormalities and cytokine dysregulation with anorexia and fatigue as clinical symptoms .17 Secondary factors can be of `mechanical’ nature, such as obstruction in the gastrointestinal tract, or malabsorption or side effects related to treatment. Nutritional intervention in patients suffering from weight loss due to secondary factors must necessarily differ from that implemented in patients with weight loss due primarily to loss of appetite. Studies have shown that weight loss can be counteracted in cancer patients.18 Thus, weight gain has been demonstrated in patients using pharmacological appetite stimulation, and nutritional deterioration was halted through the combined effect of nutrition counselling and liquid supplementation in cancer patients with advanced disease and progressive weight loss. 19,20 Artificial nutrition may also be a preferable option when weight loss is due to secondary factors.21±23 Nutritional status is conventionally assessed by means of a combination of anthropometric measurements and laboratory assessments. 24 In a clinical setting, these methods are not ideal because they are time-consuming and require a well-trained staff. The purpose of a screening tool for the nutritional assessment of cancer patients is to discover mild or moderate states of malnutrition before the patient has become overtly wasted and thus be able to attempt to prevent further deterioration. The subjective global assessment (SGA) questionnaire is a standardized instrument developed to assess nutritional

status in an easy, noninvasive and cost-effective manner.25 The patients are rated into three groups: 1) SGA-A `well nourished’; 2) SGA-B `moderately or suspectedly malnourished’; 3) SGA-C `severely malnourished’. The SGA has been validated in surgical patients and a modified form has been developed for use in cancer patients.4 The primary aim of the present study was to describe the nutritional status of a group of patients with advanced stages of their neoplastic disease, subsequent to admission to an in-patient palliative medicine unit; secondly, it aimed to validate the use of the SGA questionnaire as a screening tool against the background of the conventional objective assessment of the nutritional status of such patients.

Patients and methods Patient characteristics During a 3-month period, 80 patients were admitted to our in-patient palliative medicine unit. Only patients with advanced cancer, diagnosed by histopathological or cytodiagnostic procedures, were included. Patients obviously moribund, not willing to participate or not able to carry out an interview were excluded. Readmitted patients were not included a second time. All patients signed an informed consent before entering the study. In all, 46 patients were included. Baseline data about the patients are given in Table 1. Major reasons for exclusion were as follows: readmitted and previously interviewed (16 patients), not able to carry out an interview (6 patients), moribund (3 patients), other reasons (9 patients). The dietary intake during the last week prior to admission was estimated by a dietary history. This was impossible to obtain in 6 of 46 patients because of drowsiness, unwillingness or inability to describe their food intake. Nutritional status As stated above, nutritional status was measured by means of two different methods: 1) objective criteria, including anthropometry and assays of serum proteins; and 2) nutritional assessment by means of the SGA questionnaire. The anthropometric measurements were body mass index (BMI), triceps skinfold (TSF) thickness, and mid-upper arm muscle circumference (MAMC). The percentage change in body weight from prediagnosis body weight was calculated. One investigator (L.T.) undertook all the assessments, filled in

Nutitional status of pationts with advanced cancer 35 Table 1 Patients’ characteristics, nutritional characteristics and SGA rating in 46 patients with advanced neoplastic disease

All

Male

Female

Number of patients Age (years), mean Range

46 68 40± 88

26 69 44± 86

20 67 40 ± 80

Metastatic disease Locally advanced Distant metastasis

5 41

1 25

4 16

Male

Female

SGA rating Site of the primary tumour Oesophagus Stomach Colon/rectum Gall bladder Pancreas Bronchi Mammary gland Ovary Prostate Urinary bladder Kidney Unknown site

A

Nutritional characteristics Height (m) Weight (kg) Weight loss (kg) Weight loss (%) BMI TSF (mm) MAMC (cm) Serum albumin (g/dl) Serum prealbumin (g/l)

Mean (SD) 1.69 (0.09) 67.6 (16.8) 11.8 (10.1) 15 (12.3) 23 (4.9) 12.5 (7.0) 23.3 (2.9) 33.1 (5.1) 0.17 (0.10)

2 4 7 1 1

B 1 3 3 3 1 1 1 1

C 1 1 4 1 2 4

1 5 1 7

2

10

2

2

1 2 1 4 4 3 1 1 1 2

SGA=subjective global assessment of nutritional status; A=well nourished; B=moderately malnourished; C=severely malnourished; BMI=body mass index; TSF=triceps skinfold; MAMC=mid-upper arm muscle circumference.

the first four sections in the SGA questionnaire in cooperation with the patient and finally filled in Sections 5 and 6. Malnutrition, according to the objective method, was in this study defined as having two or more of six nutritional variables below the reference range. 26±28 The following limits were set for each variable: 1) weight loss >5% during last month or >10% during last 6 months or >15% of prediagnosis weight; 2) BMI < 20; 3) TSF µ5th percentile;29 4) MAMC µ5th percentile;29 5) serum albumin µ30 g/l; 6) serum prealbumin µ0.21 g/l. The cut-off point for serum proteins was defined as 20% below the reference value (Table 2), which indicates more than mild deficit.26,27 Anthropometry The patients were weighed without shoes and in light clothes by standing on a portable Seca digital scale. One patient was weighed on a chair scale. Height was given and measured against a wall tape. In all, seven

patients were not able to move to the bathroom where the wall tape had been installed and their heights were measured with a tape measure with the patient lying in a supine position. BMI was calculated using the formula BMI = weight (kg)/height2 (m2). Mid-upper arm circumference (MUAC) was measured on the left arm with a tape measure placed midway between the acromial process of the scapula and the tip of the elbow. TSF was measured by means of a conventional Holtain caliper.30 Three measurements were performed. The average values were used for calculation of MAMC. MAMC was calculated using formula: MAMC (cm)=MUAC (cm)¡(TSF (mm)£0.314).31 Blood samples Blood samples from a cubital vein were taken on admission and included serum albumin and serum prealbumin. Serum albumin was analysed using brom creosol green and prealbumin was analysed by means of an immunological nephelometric method. SGA questionnaire We used a modification of the original SGA developed for cancer patients.4 The SGA questionnaire is divided into six sections: weight history, food intake, symptoms,

36 Lene Thoresen et al. Table 2 Reference values for nutritional assessment

Weight loss BMI (kg/m2 )

>5% last month >10% last 6 months >15% from prediagnosis weight >25 overweight 20 ± 25 normal weight