Handgrip Strength Predicts Survival in Early Lung Cancer

Pam Harrison

April 23, 2018

Handgrip strength, as measured by a hand dynamometer, is able to predict both short- and longer-term mortality risk in patients with stage I inoperable non–small cell lung cancer (NSCLC), a prospective cohort study indicates.

"We usually look at the World Health Organization [WHO] performance status [PS] to assess mortality risk, but this is quite a subjective scale [despite the fact that] it guides doctors in their decision to treat patients," Stephanie Peeters, MD, a radiation oncologist at the MAASTRO Clinic in Maastricht, The Netherlands, told Medscape Medical News.

"So handgrip strength is a more objective measure of mortality risk, and it can help guide us in a certain direction, especially in this patient group in whom the lesions are often very slow growing and patients may die of something completely unrelated to their cancer, so they can be spared undergoing any treatment at all," she explained.

The study was presented during the European Society for Radiotherapy and Oncology (ESTRO) 37 conference, held in Barcelona, Spain.

A total of 226 patients with stage I NSCLC were included in the analysis. Handgrip strength was assessed in all patients using the Jamar hydraulic hand dynamometer.

Hand dynamometer.

All patients underwent stereotactic body radiotherapy (SBRT), which is the most common form of treatment for stage I inoperable NSCLC, being far less invasive than lobectomy, Peeters pointed out.

"Patients were instructed to grip the handle with maximal strength during 3 seconds, and this was measured three times in each hand," the investigators explain.

"Handgrip weakness was defined as maximal handgrip strength below percentile 10 of the UK Biobank reference values, taking gender, age, and height into account," they add.

At baseline, 16% of patients had a WHO PS of 0; 60% had a WHO PS of 1; 22% had a WHO PS of 2, and 3% had a WHO PS of 3. The mean age of the cohort was 72 years.

Results from the handgrip strength test showed that as a whole, the mean handgrip strength was 27 kg for the left hand and 28 kg for the right hand.

Handgrip strength varied from a low of 17 kg to a high of 39 kg.

Almost one third (31%) of patients showed evidence of handgrip weakness; 69% of patients showed no sign of handgrip weakness.

Multivariate Analysis

On multivariate analysis, researchers found that patients with handgrip weakness were 52% more likely to die within 5 years compared to patients with a strong handgrip (hazard ratio [HR], 1.52; P = .04).

At 5 years, 12% of patients with handgrip weakness were still alive, compared to 40% of patients who did not demonstrate handgrip weakness.

In addition, male sex, increasing age, and lower body mass index (BMI) were all significantly associated with poorer overall survival at 5 years.

Table. Mortality Risk at 5 Years*

  Hazard Ratio P Value
Male sex 1.80 0.04
Age (for each year added) 1.03 0.02
Lower BMI (per each kg/m2) 0.93 0.01
*Based on multivariate analysis of various risk factors

 

The researchers found that even at 1 year, handgrip strength was an independent predictor of overall survival (HR, 1.98; P = .04).

In contrast, baseline WHO PS 2 or more was no longer a significant predictor of overall survival at 5 years (HR, 1.38; P = .12), although it was a significant predictor of overall survival on univariate analysis at the same study endpoint.

"It's not always easy for a physician to get a good idea about the general condition of a patient based on only one or a few visits," Peeters said in a statement.

"In this study, we have shown that handgrip strength provides additional information to help evaluate survival, which may help guide physicians in how to manage the lung tumor," she added.

For example, it is sometimes unclear whether a patient should be treated with surgery or with SBRT, Peeters noted.

"In this situation, if you know a patient has a lower life expectancy, then we should go for the treatment that is much less invasive, which is SBRT," she observed.

Commenting on the study, ESTRO President Yolande Lievens, MD, PhD, head of radiation oncology, Ghent University Hospital, Belgium, reminded delegates of the importance of assessing the patient before deciding on treatment. To ensure that patients enjoy the best quality of life they can while also receiving effective therapy, physicians are obliged to weigh the potential survival gains offered by that treatment against its potential to adversely affect quality of life, she said.

"This interesting study shows that a simple handgrip test provides doctors with an objective, cheap, and easy way to assess their patients' overall health, which will help them in deciding on the best way of managing the cancer," Lievens stated.

Lievens added that although the test provides interesting information for patients with early-stage lung cancer, "it may prove even more interesting in more advanced tumor stages, [in which] the risk of toxicity from combed chemoradiotherapy schedules is more important than after SBRT."

In a study from 2013, handgrip strength was shown to be independently associated with overall survival and quality of life in patients with advanced cancer.

In that study, which included 203 patients with advanced cancer, the investigators found that for patients with low handgrip strength, BMI was lower, survival times were shorter, and quality of life was poorer compared to other study patients.

These findings suggest that patients who present with pronounced handgrip weakness may require referral to supportive or palliative care services, the authors of that study suggested.

The study received no external funding. Dr Lievens has disclosed no relevant financial relationships.

European Society for Radiotherapy and Oncology (ESTRO) 37. Abstract PV0041, presented April 21, 2018.

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