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ONC: Nutrition Status and Outcomes in Adult Oncology Patients (2013)

Citation:

Pressoir M, Desne S, Berchery D, Rossignol G, Poiree B, Meslier M, Traversier S, Vittot M, Simon M, Gekiere JP, Meuric J, Serot F, Falewee MN, Rodriquez I, Senesse P, Vasson MP, Chelle F, Maget B, Antoun S, Bachmann P. Prevalence, risk factors and clinical implications of malnutrition in French comprehensive cancer centers. British Journal of Cancer. 2010: 102, 966-971.

PubMed ID: 20160725
 
Study Design:
Prospective Cohort Study
Class:
B - Click here for explanation of classification scheme.
Quality Rating:
Positive POSITIVE: See Quality Criteria Checklist below.
Research Purpose:

To determine the prevalence of malnutrition during hospitalization in cancer centers and to identify potential risk factors for malnutrition.

Inclusion Criteria:
  • Admitted to participating cancer center between October 2007 and January 2008 with hospitalization on the day the study was conducted
  • 18 years of age or more
  • Presence of malignant diagnosis prior to discharge from hospital.
Exclusion Criteria:
  • Less than 18 years of age
  • Absence of malignant diagnosis at end of stay
  • Patients in agony.
Description of Study Protocol:

Recruitment

Recruited from voluntary cancer centers

Design

  • Between October 2007 and January 2008, each participating cancer center chose one day to conduct the study
    • Study conducted on Tuesday, Wednesday or Thursday
  • All adult hospitalized patients from every unit or ward were included on the same day
  • The following data was collected:
    • Height
    • Weight from six months prior
    • Current weight
    • Patient's date of birth
    • Gender
    • Type of hospitalization
    • Site of primary tumor
    • Presence of distant metastasis
    • Treatment received during the stay or in relation to current hospitalization
    • Prescription of antibiotics during hospitalization
    • Type of nutrition support until day of surgery
  • Length of hospital stay and patient status was evaluated at two months after the initial study day.

Intervention

None, observational study.

Statistical Analysis

  • Qualitative data summarized as frequencies and results expressed as means and standard deviations
  • Association between malnutrition and clinical status assessed using x2 test or Fisher's exact test and analyses of variance for categorical and continuous measurements, respectively
  • P<0.05 consider statistically significant
  • Backward stepwise logistic regression analysis performed on variables associated with P<0.20
  • Logistic regression used to determine whether malnutrition was independent factor of mortality.
Data Collection Summary:

Timing of Measurements

  • Weight, height, weight six months prior to study day, patient birth date, gender, type of hospitalization, site of primary tumor, presence of distant metastases, treatment received during stay or in relation to current hospitalization, prescription of antibiotics during current stay, performance status and type of nutrition support until study day
  • Length of stay was determined two months after study day
  • Patient status (alive, dead or unknown) was determined at two months after study day.

Variables

  • Presence of malnutrition:
    • Absent
    • Moderate:
      • Age 70 years or less with weight loss over the past six months 10% or more, or BMI less than 18.5
      • Age older than 70 years with weight loss over the past six months 10% or more or BMI less than 21
    • Severe: 
      • Age 70 years or less with weight loss over the past six months 15% or more or BMI less than 16
      • Age 70 years or more with weight loss over the past six months 15% or more or BMI less than 18
  • Body mass index in kg/m2
  • Weight loss over six months prior to study as reported by patient
  • Site of primary tumor
  • Presence of distant metastases 
  • Treatment received during current stay
    • Surgery
    • Radiotherapy
    • Chemotherapy
  • Nutrition support received prior to study day
    • Dietetic counseling
    • Enteral nutrition
    • Parenteral nutrition
  • Prescription of antibiotics with exception of antibiotic prophylaxis for surgery
  • Length of hospital stay in days
  • Patient status (dead, alive or unknown)
  • Performance status determined on day of study using definition determined by World Health Organization
  • Age
  • Gender
  • Type of hospitalization:
    • Conventional
    • Outpatient.
Description of Actual Data Sample:
  • Initial N: 1,545 patients (885 women, 660 men)
  • Attrition (final N): 1,364 patients with adequate data to determine nutrition status, 1,081 patients available for follow-up at two months after study day
  • Age: Median age 59.3±13.8 years with 361 patients (23.4%)  older than 70 years
  • Anthropometrics: Significance of difference of BMI among differing sites of primary tumors
  • Location: Multi-center trial in France.
Summary of Results:

 Key Findings

  • Overall prevalence of malnutrition was 30.9% with 18.6% and 12.2% cases of moderate or severe malnutrition, respectively
  • 60.4% of patients reported weight loss in the previous six months
  •  BMI relatively low sensitivity indicator of malnutrition; identified only 12.4% of the 30.9% of patients with malnutrition
  • 62% of malnourished patients received nutritional support vs. 31.7% in the absence of malnutrition (P<0.001)
  • Male gender, presence of metastases, inpatient hospitalization, palliative care and radiotherapy are associated with malnutrition
  • Obese patients were more prone to malnutrition (38.8% vs. 28.5%, P<0.01); in these patients only the risk of severe malnutrition seemed significant (OR=2.26; 95% CI:1.5-3.4, P<0.0001)
  • Prevalence of malnutrition was moderately associated with WHO PS, with major increase in patient with PS≥2
  • Antibiotic  intake was significantly increased in malnourished patients (35.5% vs. 22.8%; P<0.001)
  • In multi-variate analysis, only obesity at six months before study, poor functional status (PS≥2) and head and neck or upper digestive cancers were independently associated with malnutrition
  • On two-month follow-up, mortality (18.4%) was significantly higher in malnourished patients than in other group (26.7% vs. 11.8%; P<0.0001; OR 2.7 (1.9 to 3.9) as well as higher in patients for whom no weight or height information was available (25.7% vs. 17.6%; P=0.045
  • Multi-variate analysis accounting for major confounding factors showed that only severe malnutrition was independently associated with mortality 
  • Malnutrition, either moderate or severe, was significantly associated with prolonged LOS with median LOS 19.3+19.4 days for malnourished patients vs. 13.3=19.4 days for other patients (P<0.0001)
  • Nutritional status did not remain significant when compared with other confounding factors possibly associated with prolonged LOS
  • Only PS, head and neck cancers, hematological malignancies and terminal stage remained significantly associated with prolonged LOS.

Factors Indecently Associated with Malnutrition

Risk Factors Odds Ratio 95% CI P Value
BMI 30kg/m2 or more 1.58 1.08 to 2.31 0.018
PS two or more 2.71 2.30 to 6.70 <0.01
Digestive cancer 3.39 1.89 to 6.10 <0.01
Head and neck and cancer 2.28 1.53 to 3.41 <0.01

 

 Factors Independently Associated with Mortality

Risk Factors Odds Ratio 95% CI P Value
Presence of metastases 2.21 1.3 to 3.73  0.03 
Palliation 3.96  2.17 to 7.25  <0.001 
Evaluation 2.80  1.38 to 5.69  0.004 
Hematological malignancy 2.43 1.17 to 5.03  0.017 
Gynecological cancer 2.34  1.14 to 4.83  0.021 
Lung cancer 2.85  1.37 to 5.93  0.005 
WHO PS   
PS 2 2.19  1.18 to 4.05  0.013 
PS 3 4.12  2.2 to 7.72  <0.001 
PS 4 8.77  4.08 to 18.9  <0.001 
Severe malnutrition 2.47  2.2 to 7.72  0.002 
Age higher than 70 years 2.01  1.21 to 3.34  0.007 

 

 

Author Conclusion:

The prevalence of malnutrition, defined as a function of two anthropometric indicators BMI and weight loss, was 30.9%. This morbidity related to disease or to treatment is associated with an impaired functional status, more frequent use of antibiotics and higher mortality. The length of stay is 45% longer for malnourished patients than for others, most likely owing to poorer PS. This is the first report of obesity as possible risk factor for malnutrition.

Funding Source:
Industry:
Nutricia France
Pharmaceutical/Dietary Supplement Company:
Not-for-profit
Asymptote Society
Reviewer Comments:

Weight from six months previous was self-reported by patient.

Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) Yes
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) Yes
 
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? Yes
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? Yes
  2.2. Were criteria applied equally to all study groups? Yes
  2.3. Were health, demographics, and other characteristics of subjects described? Yes
  2.4. Were the subjects/patients a representative sample of the relevant population? Yes
3. Were study groups comparable? Yes
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) N/A
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? N/A
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) N/A
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? Yes
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? Yes
  4.1. Were follow-up methods described and the same for all groups? Yes
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) Yes
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? Yes
  4.4. Were reasons for withdrawals similar across groups? Yes
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? N/A
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) N/A
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? Yes
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? N/A
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? Yes
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? Yes
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? Yes
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? Yes
  6.6. Were extra or unplanned treatments described? Yes
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? Yes
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? Yes
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? Yes
  7.6. Were other factors accounted for (measured) that could affect outcomes? Yes
  7.7. Were the measurements conducted consistently across groups? Yes
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? Yes
  8.1. Were statistical analyses adequately described and the results reported appropriately? Yes
  8.2. Were correct statistical tests used and assumptions of test not violated? Yes
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? Yes
  8.6. Was clinical significance as well as statistical significance reported? Yes
  8.7. If negative findings, was a power calculation reported to address type 2 error? N/A
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes