506940
research-article2014
PENXXX10.1177/0148607113506940Journal of Parenteral and Enteral NutritionMarian and August
Commentary
Prevalence of Malnutrition and Current Use of Nutrition Support in Cancer Patient Study Mary Marian, MS, RDN, CSO1; and David A. August, MD2
In this issue of JPEN, Hébuterne and colleagues report the prevalence of malnutrition in patients with cancer in France.1 In this cross-sectional study, patients with a variety of cancers, who were either hospitalized or treated for day care, radiographic studies, or follow-up in an ambulatory clinic, were enrolled. Data on demographic and clinical characteristics (eg, type and stage of cancer, etc), weight history, and performance status were analyzed. Criteria used to identify included weight history (current weight vs usual body weight) and body mass index (BMI); and when a recent albumin level was available (with in the past week), the nutrition risk index (NRI) was calculated (NRI = [1.519 × serum albumin g/dL] + 41.7 [current weight/usual body weight]). The prevalence of malnutrition was high in this study, but in line with previously reported surveys. The overall incidence of what the authors report as malnutrition was 39%; 44.1% of patients hospitalized and 27.7% of patients seen in ambulatory clinics were identified as malnourished by the authors’ criteria.1 The incidence of malnutrition was related to disease stage; 22.7% of patients with localized disease, 44.3% of patients with loco-regional disease, and 45.9% of patients with metastatic disease were assessed by the authors as malnourished.1 These findings are consistent with other reports, but it is important to keep in mind that these numbers are heavily influenced by the criteria used to diagnose malnutrition.2-4 There are some problematic aspects of this study. First, the use of BMI at the time of study enrollment alone as a marker of catabolism and malnutrition may not be appropriate because it does not take into consideration non-nutrition influences on BMI such as edema, ascites, or a low but stable index. Second, the authors’ use of weight loss between the time of cancer diagnosis and study enrollment may not be an accurate indicator of malnutrition. Although 84% of the patients studied had lost >10% of their usual body weight at the time of study enrollment, the investigators did not observe the time course of this weight loss.1 Did patients lose weight within 6 months of their assessment, or did weight loss occur over much longer periods of time?5 Cancer is becoming a chronic disease and weight loss may occur acutely or chronically, with or without intervening periods of stability during the cancer continuum. Since it is likely that catabolism is the major mediator of the devastating consequences of cancer inducing malnutrition and cachexia rather than simple anthropometric measures, the authors’ definition of malnutrition in this study may either over-estimate or under-estimate the clinical and quality of life significance of
Journal of Parenteral and Enteral Nutrition Volume 38 Number 2 February 2014 163–165 © 2014 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0148607113506940 jpen.sagepub.com hosted at online.sagepub.com
their findings, depending upon the acuity and time course of the development of weight loss and low BMI. Similarly, use of NRI may be problematic. Relying as it does on the serum albumin level, the NRI may in fact be more indicative of severity of disease than of true malnutrition.5 Screening for and diagnosing malnutrition in oncology patients is important as malnutrition is associated with numerous adverse events such as perioperative complications, poor tolerance of and delays in treatment, poorer quality of life, and increased morbidity and mortality.6,7 Anorexia, early satiety, the presence of inflammatory and catabolic mediators, and a host of other factors contribute to the nutrition deterioration seen in cancer patients in addition to antineoplastic treatments and the disease itself.6,7 Early, accurate, and reproducible identification of developing or existing malnutrition in these patients may afford the best opportunity to prevent or reverse the devastating consequences of malnutrition in cancer patients.8 An international consensus panel recently published criteria for the diagnosis of cancer cachexia, in part to standardize definitions for use in trials and in patient care.9 The panel established the following criteria for diagnosing cancer cachexia in patients who have not entered the refractory period: weight loss > 5% over the past 6 months (in the absence of simple starvation) or a BMI < 20 kg/m2 with weight loss > 2%.9 Determining which patients may have refractory cachexia is key as nutrition interventions are not likely to reverse or prevent further deterioration; nutrition interventions at this point are likely not appropriate.9 In the current study, many patients presented with advanced disease. The modern approach to the diagnosis of malnutrition recognizes that a pallet of metrics is required to accurately diagnose and characterize malnutrition in patients. This necessitates the use of anthropometric, laboratory, and disease related measures to create a nutrition assessment that can result in a disease and patient appropriate set of recommendations for From 1University of Arizona, Tucson, Arizona; and 2Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey. Received for publication September 3, 2013; accepted for publication September 5, 2013. Corresponding Author: Mary Marian, MS, RDN, CSO, Arizona Oncology Associates Consultant, University of Arizona, Colleges of Agriculture & Life Sciences, College of Medicine, 6310 N Canon del Pajaro, Tucson, AZ 85750, USA. Email: [email protected].
Downloaded from pen.sagepub.com at SETON HALL UNIV on April 27, 2015
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Journal of Parenteral and Enteral Nutrition 38(2)
optimal management of nutrition status. In 2009, the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) and the European Society for Clinical Nutrition and Metabolism (E.S.P.E.N.) convened an international guideline committee of nutrition experts to develop a “consensus approach to defining malnutrition syndromes in adults in clinical settings.”10 The committee arrived at 3 etiology-based definitions for diagnosing malnutrition that reflect not only the impact of inadequate nutrient intake that promotes malnutrition, but also the role of inflammation and underlying disease as etiologic mediators.10 The following etiology-based definitions for malnutrition were proposed:10 •• Starvation-related malnutrition: pure chronic starvation (eg, anorexia nervosa) •• Chronic disease-related malnutrition (eg, organ failure, pancreatic cancer, rheumatoid arthritis, sarcopenic obesity, etc resulting in mild-moderate inflammation) •• Acute disease or injury-related malnutrition (eg, major infection, burns, trauma, closed head injury, etc resulting in moderate-severe malnutrition). These recommendations have been accepted not only by the 2 convening organizations, but also by the Academy of Nutrition and Dietetics.11 Following the development of these etiology-based definitions for malnutrition, the Academy and A.S.P.E.N. developed the following list of metrics to detect and diagnose malnutrition:10,11 •• •• •• •• ••
Insufficient energy intake Weight loss Loss of muscle mass Loss of subcutaneous fat Localized or generalized fluid accumulation that may mask weight loss •• Diminished functional status as measured by hand grip strength Criteria are available that delineate how to measure each of the indicators with the recommendation that 2 or more characteristics be present for the diagnosis of malnutrition.5,11 In oncology, others have addressed the problem of malnutrition, particularly cancer cachexia.8 A definition and classification of cancer cachexia was published in 2011 by another international group of experts in clinical cancer cachexia research.9 Cancer cachexia was defined as “a multifactorial syndrome characterized by an ongoing loss of skeletal muscle mass (with or without loss of fat mass) that cannot be fully reversed by conventional nutrition support and leads to progressive functional impairment.”9 Furthermore, cancer cachexia was broken into 3 stages: precachexia, cachexia, and refractory cachexia. As noted by Evans et al, “Cachexia is infrequently identified or diagnosed and rarely treated.12 This
may be due to the mistaken belief that cancer cachexia is associated with untreatable cancer and is thereby irreversible.12 Researchers in the field now stress that recognizing the onset or the presence of nutrition-related impact factors associated with promoting cachexia is critical in patient care to guide the initiation of appropriate therapies.9 For example, it is important to distinguish between cachexia and refractory cachexia as the burden and risk of nutrition interventions are likely to outweigh the potential benefits for patients with refractory cachexia.9 In conclusion, while the findings of the study by Hébuterne et al1 are important and affirm that malnutrition is prevalent in cancer patients, until investigations exploring the incidence of malnutrition in the cancer setting move away from using traditional measures such as serum albumin and BMI, the true extent and impact of the problem will not be understood. Modern approaches that emphasize the contributions of etiology and underlying disease must be used to better reflect the impact of physiology and inflammation on nutrition status. A standardized approach to diagnosing and documenting malnutrition is needed in practice to truly document the prevalence and incidence of malnutrition in all practice settings, including oncology, and to show us the way to better treating this problem.5,9-11
References 1. Hébuterne X, Lamarié E, Michallet M, Beauvillian de Montreuil C, Schneider S, Goldwasser F. Prevalence of malnutrition and current use of nutrition support in cancer patients. JPEN J Parenter Enteral Nutr. 2014; 38:196-204. 2. LaTorre M, Ziparo V, Nigri G, Cavallini M, Balducci G, Ramacciato G. Malnutrition and pancreatic surgery: prevalence and outcomes. J Surg Oncol. 2013;107(7):702-708. 3. Koom WS, Ahn SD, Song SY, et al. Nutritional status of patients treated with radiotherapy as determined by subjective global assessment. Radiat Oncol J. 2012;30(3):132-139. 4. Thoresen L, Frykholm G, Lydersen S, et al. Nutritional status, cachexia and survival in patients with advanced colorectal carcinoma. Different assessment criteria for nutritional status provide unequal results. Clin Nutr. 2013;32(1):65-72. 5. Tappenden KA, Quatrara B, Parkhurst ML, Malone AM, Fanjiang G, Ziegler TR. Critical role of nutrition in improving quality of care: an interdisciplinary call to action to address adult hospital malnutrition. JPEN J Parenter Enteral Nutr. 2013;37:482-497. 6. Morgan TM, Tang D, Stratton KL, et al. Preoperative nutritional status is an important predictor of survival in patients undergoing surgery for renal cell cancer. Eur Urol. 2011;59(6):923-928. 7. Tong H, Isenring E, Yates P. The prevalence of nutrition impact symptoms and their relationship to quality of life and clinical outcomes in medical oncology patients. Support Care Cancer. 2009;17(1):83-90. 8. August D, Huhmann MB. Nutrition support of the cancer patient. In: Ross A, Caballero B, Cousins R, Tucker K, and Ziegler T, eds. Modern Nutrition in Health and Disease. 11th ed. New York, NY: Lippincott, Williams & Wilkins; 2012: 1297–1326. 9. Fearon K, Strasser F, Anker SD, et al. Definition and classification of cancer cachexia: an international consensus. Lancet Oncol. 2011;12: 489-495. 10. Jensen GL, Mirtallo J, Compher C, et al. Adult starvation and disease-related malnutrition: a proposal for etiology-based diagno-
Downloaded from pen.sagepub.com at SETON HALL UNIV on April 27, 2015
Marian and August
165
sis in the clinical practice setting from the International Consensus Guideline Committee. JPEN J Parenter Enteral Nutr. 2010;34(2): 156-159. 11. White JV, Guenter P, Jensen G, Malone A, Schofield M. Consensus statement: Academy of Nutrition and Dietetics and American Society for
Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). JPEN J Parenter Enteral Nutr. 2012;36:275-283. 12. Evans WJ, Morley JE, Argilès J, et al. Cachexia: a new definition. Clin Nutr. 2008;27(6):793-799.
Downloaded from pen.sagepub.com at SETON HALL UNIV on April 27, 2015
research-article2014
PENXXX10.1177/0148607113506940Journal of Parenteral and Enteral NutritionMarian and August
Commentary
Prevalence of Malnutrition and Current Use of Nutrition Support in Cancer Patient Study Mary Marian, MS, RDN, CSO1; and David A. August, MD2
In this issue of JPEN, Hébuterne and colleagues report the prevalence of malnutrition in patients with cancer in France.1 In this cross-sectional study, patients with a variety of cancers, who were either hospitalized or treated for day care, radiographic studies, or follow-up in an ambulatory clinic, were enrolled. Data on demographic and clinical characteristics (eg, type and stage of cancer, etc), weight history, and performance status were analyzed. Criteria used to identify included weight history (current weight vs usual body weight) and body mass index (BMI); and when a recent albumin level was available (with in the past week), the nutrition risk index (NRI) was calculated (NRI = [1.519 × serum albumin g/dL] + 41.7 [current weight/usual body weight]). The prevalence of malnutrition was high in this study, but in line with previously reported surveys. The overall incidence of what the authors report as malnutrition was 39%; 44.1% of patients hospitalized and 27.7% of patients seen in ambulatory clinics were identified as malnourished by the authors’ criteria.1 The incidence of malnutrition was related to disease stage; 22.7% of patients with localized disease, 44.3% of patients with loco-regional disease, and 45.9% of patients with metastatic disease were assessed by the authors as malnourished.1 These findings are consistent with other reports, but it is important to keep in mind that these numbers are heavily influenced by the criteria used to diagnose malnutrition.2-4 There are some problematic aspects of this study. First, the use of BMI at the time of study enrollment alone as a marker of catabolism and malnutrition may not be appropriate because it does not take into consideration non-nutrition influences on BMI such as edema, ascites, or a low but stable index. Second, the authors’ use of weight loss between the time of cancer diagnosis and study enrollment may not be an accurate indicator of malnutrition. Although 84% of the patients studied had lost >10% of their usual body weight at the time of study enrollment, the investigators did not observe the time course of this weight loss.1 Did patients lose weight within 6 months of their assessment, or did weight loss occur over much longer periods of time?5 Cancer is becoming a chronic disease and weight loss may occur acutely or chronically, with or without intervening periods of stability during the cancer continuum. Since it is likely that catabolism is the major mediator of the devastating consequences of cancer inducing malnutrition and cachexia rather than simple anthropometric measures, the authors’ definition of malnutrition in this study may either over-estimate or under-estimate the clinical and quality of life significance of
Journal of Parenteral and Enteral Nutrition Volume 38 Number 2 February 2014 163–165 © 2014 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0148607113506940 jpen.sagepub.com hosted at online.sagepub.com
their findings, depending upon the acuity and time course of the development of weight loss and low BMI. Similarly, use of NRI may be problematic. Relying as it does on the serum albumin level, the NRI may in fact be more indicative of severity of disease than of true malnutrition.5 Screening for and diagnosing malnutrition in oncology patients is important as malnutrition is associated with numerous adverse events such as perioperative complications, poor tolerance of and delays in treatment, poorer quality of life, and increased morbidity and mortality.6,7 Anorexia, early satiety, the presence of inflammatory and catabolic mediators, and a host of other factors contribute to the nutrition deterioration seen in cancer patients in addition to antineoplastic treatments and the disease itself.6,7 Early, accurate, and reproducible identification of developing or existing malnutrition in these patients may afford the best opportunity to prevent or reverse the devastating consequences of malnutrition in cancer patients.8 An international consensus panel recently published criteria for the diagnosis of cancer cachexia, in part to standardize definitions for use in trials and in patient care.9 The panel established the following criteria for diagnosing cancer cachexia in patients who have not entered the refractory period: weight loss > 5% over the past 6 months (in the absence of simple starvation) or a BMI < 20 kg/m2 with weight loss > 2%.9 Determining which patients may have refractory cachexia is key as nutrition interventions are not likely to reverse or prevent further deterioration; nutrition interventions at this point are likely not appropriate.9 In the current study, many patients presented with advanced disease. The modern approach to the diagnosis of malnutrition recognizes that a pallet of metrics is required to accurately diagnose and characterize malnutrition in patients. This necessitates the use of anthropometric, laboratory, and disease related measures to create a nutrition assessment that can result in a disease and patient appropriate set of recommendations for From 1University of Arizona, Tucson, Arizona; and 2Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey. Received for publication September 3, 2013; accepted for publication September 5, 2013. Corresponding Author: Mary Marian, MS, RDN, CSO, Arizona Oncology Associates Consultant, University of Arizona, Colleges of Agriculture & Life Sciences, College of Medicine, 6310 N Canon del Pajaro, Tucson, AZ 85750, USA. Email: [email protected].
Downloaded from pen.sagepub.com at SETON HALL UNIV on April 27, 2015
164
Journal of Parenteral and Enteral Nutrition 38(2)
optimal management of nutrition status. In 2009, the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) and the European Society for Clinical Nutrition and Metabolism (E.S.P.E.N.) convened an international guideline committee of nutrition experts to develop a “consensus approach to defining malnutrition syndromes in adults in clinical settings.”10 The committee arrived at 3 etiology-based definitions for diagnosing malnutrition that reflect not only the impact of inadequate nutrient intake that promotes malnutrition, but also the role of inflammation and underlying disease as etiologic mediators.10 The following etiology-based definitions for malnutrition were proposed:10 •• Starvation-related malnutrition: pure chronic starvation (eg, anorexia nervosa) •• Chronic disease-related malnutrition (eg, organ failure, pancreatic cancer, rheumatoid arthritis, sarcopenic obesity, etc resulting in mild-moderate inflammation) •• Acute disease or injury-related malnutrition (eg, major infection, burns, trauma, closed head injury, etc resulting in moderate-severe malnutrition). These recommendations have been accepted not only by the 2 convening organizations, but also by the Academy of Nutrition and Dietetics.11 Following the development of these etiology-based definitions for malnutrition, the Academy and A.S.P.E.N. developed the following list of metrics to detect and diagnose malnutrition:10,11 •• •• •• •• ••
Insufficient energy intake Weight loss Loss of muscle mass Loss of subcutaneous fat Localized or generalized fluid accumulation that may mask weight loss •• Diminished functional status as measured by hand grip strength Criteria are available that delineate how to measure each of the indicators with the recommendation that 2 or more characteristics be present for the diagnosis of malnutrition.5,11 In oncology, others have addressed the problem of malnutrition, particularly cancer cachexia.8 A definition and classification of cancer cachexia was published in 2011 by another international group of experts in clinical cancer cachexia research.9 Cancer cachexia was defined as “a multifactorial syndrome characterized by an ongoing loss of skeletal muscle mass (with or without loss of fat mass) that cannot be fully reversed by conventional nutrition support and leads to progressive functional impairment.”9 Furthermore, cancer cachexia was broken into 3 stages: precachexia, cachexia, and refractory cachexia. As noted by Evans et al, “Cachexia is infrequently identified or diagnosed and rarely treated.12 This
may be due to the mistaken belief that cancer cachexia is associated with untreatable cancer and is thereby irreversible.12 Researchers in the field now stress that recognizing the onset or the presence of nutrition-related impact factors associated with promoting cachexia is critical in patient care to guide the initiation of appropriate therapies.9 For example, it is important to distinguish between cachexia and refractory cachexia as the burden and risk of nutrition interventions are likely to outweigh the potential benefits for patients with refractory cachexia.9 In conclusion, while the findings of the study by Hébuterne et al1 are important and affirm that malnutrition is prevalent in cancer patients, until investigations exploring the incidence of malnutrition in the cancer setting move away from using traditional measures such as serum albumin and BMI, the true extent and impact of the problem will not be understood. Modern approaches that emphasize the contributions of etiology and underlying disease must be used to better reflect the impact of physiology and inflammation on nutrition status. A standardized approach to diagnosing and documenting malnutrition is needed in practice to truly document the prevalence and incidence of malnutrition in all practice settings, including oncology, and to show us the way to better treating this problem.5,9-11
References 1. Hébuterne X, Lamarié E, Michallet M, Beauvillian de Montreuil C, Schneider S, Goldwasser F. Prevalence of malnutrition and current use of nutrition support in cancer patients. JPEN J Parenter Enteral Nutr. 2014; 38:196-204. 2. LaTorre M, Ziparo V, Nigri G, Cavallini M, Balducci G, Ramacciato G. Malnutrition and pancreatic surgery: prevalence and outcomes. J Surg Oncol. 2013;107(7):702-708. 3. Koom WS, Ahn SD, Song SY, et al. Nutritional status of patients treated with radiotherapy as determined by subjective global assessment. Radiat Oncol J. 2012;30(3):132-139. 4. Thoresen L, Frykholm G, Lydersen S, et al. Nutritional status, cachexia and survival in patients with advanced colorectal carcinoma. Different assessment criteria for nutritional status provide unequal results. Clin Nutr. 2013;32(1):65-72. 5. Tappenden KA, Quatrara B, Parkhurst ML, Malone AM, Fanjiang G, Ziegler TR. Critical role of nutrition in improving quality of care: an interdisciplinary call to action to address adult hospital malnutrition. JPEN J Parenter Enteral Nutr. 2013;37:482-497. 6. Morgan TM, Tang D, Stratton KL, et al. Preoperative nutritional status is an important predictor of survival in patients undergoing surgery for renal cell cancer. Eur Urol. 2011;59(6):923-928. 7. Tong H, Isenring E, Yates P. The prevalence of nutrition impact symptoms and their relationship to quality of life and clinical outcomes in medical oncology patients. Support Care Cancer. 2009;17(1):83-90. 8. August D, Huhmann MB. Nutrition support of the cancer patient. In: Ross A, Caballero B, Cousins R, Tucker K, and Ziegler T, eds. Modern Nutrition in Health and Disease. 11th ed. New York, NY: Lippincott, Williams & Wilkins; 2012: 1297–1326. 9. Fearon K, Strasser F, Anker SD, et al. Definition and classification of cancer cachexia: an international consensus. Lancet Oncol. 2011;12: 489-495. 10. Jensen GL, Mirtallo J, Compher C, et al. Adult starvation and disease-related malnutrition: a proposal for etiology-based diagno-
Downloaded from pen.sagepub.com at SETON HALL UNIV on April 27, 2015
Marian and August
165
sis in the clinical practice setting from the International Consensus Guideline Committee. JPEN J Parenter Enteral Nutr. 2010;34(2): 156-159. 11. White JV, Guenter P, Jensen G, Malone A, Schofield M. Consensus statement: Academy of Nutrition and Dietetics and American Society for
Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). JPEN J Parenter Enteral Nutr. 2012;36:275-283. 12. Evans WJ, Morley JE, Argilès J, et al. Cachexia: a new definition. Clin Nutr. 2008;27(6):793-799.
Downloaded from pen.sagepub.com at SETON HALL UNIV on April 27, 2015
