Older Cancer Patients at Greater Risk for Malnutrition

Nancy A. Melville

September 12, 2019

Malnutrition is common among cancer patients of all ages, but older cancer patients are particularly at risk, a new study suggests.

The study involved nearly 5000 hospitalized patients with various cancers.

It found higher rates of malnutrition among cancer patients older than 65 years compared to younger patients. It found an increase in symptoms linked to malnutrition, such as loss of appetite, in patients older than 50 years.

"These results highlight the need for nutritional screening and assessment both for characteristics of malnutrition and for underlying risk factors soon after hospitalization to enable early and multidisciplinary or interdisciplinary interventions," say the authors.

The study was published online on September 9 in Cancer.

Lead author Nivaldo de Pinho, PhD, of the National Cancer Institute José Alencar Gomes da Silva, in Rio de Janeiro, Brazil, emphasized that with the timely detection of symptoms, clinicians can prevent the advancement of malnutrition.

"Many of these occurrences can be minimized with nutritional counseling and oral nutritional support," de Pinho told Medscape Medical News.

"Counseling tells the patient what to do to prevent and treat these signs and symptoms, and nutritional support corrects the calorie and protein deficit," he said.

Early, specialized action by professional nutritionists is often required, and the evidence underscores the likely need for using different treatment regimens according to the cancer type, de Pinho noted.

"Some types of tumors require longer follow-up during and after treatment," he said.

"Chemotherapy, radiotherapy, and digestive and head and neck surgery promote a higher prevalence of signs and symptoms of nutritional impact that will further debilitate these cancer patients," he added.

Ubiquitous but Neglected Problem

The problem was highlighted by US oncologists in a recent article in the Journal of Oncology Practice. In that article, the authors describe malnutrition in cancer patients as "the elephant in the room."

"It is incomprehensible that severe body wasting in patients with cancer is ignored or viewed as inevitable," writes Declan Walsh, MD, from the Department of Supportive Oncology at the Levine Cancer Institute, in Charlotte, North Carolina, and colleagues.

"Malnutrition in patients with cancer is a ubiquitous but neglected problem and should be (but is not) a strategic priority in cancer care," they comment.

Survey of Nearly 5000 Patients

The new findings come from the Brazilian Survey of Oncology Nutrition, which enrolled 4783 cancer patients aged 20 years or older who were admitted to 45 hospitals in Brazil between August and November 2012. The mean age of the patients was 56.7 years; more than half (52.4%) were women. Of note, among patients aged 65 and older, 57.1% were men, and of those aged 50 years or younger, 64.1% were women.

Assessments of patients' nutritional status, nutritional risk, and symptoms that have an impact on nutrition were made during the first 24 hours of hospitalization using the Patient-Generated Subjective Global Assessment (PG-SGA).

The overall rate of malnutrition was 45.3%; this included both stage B (moderate/suspected) malnutrition, and stage C malnutrition (severe malnourishment).

The prevalence of malnutrition was higher among patients aged 65 and older, at 55%. This rate was significantly higher than the 36.1% among those aged 50 or younger and the 48.4% among those aged 54 – 64 (P < .001).

Severe nutrition was present in 14.6% of those aged 65 or older and in 12.5% of those aged 51 – 64.

Regarding the prevalence of symptoms affecting nutrition, the authors found that compared to those aged 50 or younger, patients who were 65 years or older had significantly higher rates of having no appetite (odds ratio [OR], 1.90) and dry mouth (OR, 1.40; both P < .05).

Compared to patients aged 50 or younger, those in the 51 – 64 age group had significantly higher rates of an absence of appetite (OR, 1.45), as well as dry mouth (OR, 1.22) and problems with swallowing (OR, 1.56, all P < .05).

"Although almost one-quarter of patients in the youngest age group (≤50 years) had no appetite, even more than one-third of the oldest age group (≥65 years) had this NIS [nutritional impact symptom]," the authors comment.

Symptom Prevalence Varies by Cancer Type

The prevalence of having no appetite ranged from 21.8% to 44.6%, depending on cancer type. The highest rates of appetite loss were seen among patients with lung cancer (OR, 2.88; P < .001), whereas nausea was more prevalent among patients with gynecologic cancer (11.6% – 27.9%; OR, 2.13; P < .001).

Among patients with upper digestive cancer, rates were higher for vomiting (OR, 3.07) and dry month (OR, 1.69; both P < .001).

As could be expected, rates of problems involving swallowing were notably higher among patients with head and neck cancer, at 40.2% (OR, 11.59; P < .001).

Assessment With PG-SGA Encouraged

For diagnosing malnutrition in cancer patients, the authors advocate use of the PG-SGA.

"Although various tools have been used to evaluate nutritional status or nutritional risk in patients with cancer, the PG-SGA is not only the most frequently used tool but, together with the Subjective Global Assessment and the Mini–Nutritional Assessment, the PG-SGA is also among the few tools that cover all domains of the construct of malnutrition and is recommended by European Society for Clinical Nutrition and Metabolism," they note.

Importantly, the PG–SGA addresses the highest number of symptions that have nutritional impact, which can be considered risk factors for malnutrition.

"Identifying the causes of problems with eating (using box 3 on the PG–SGA questionnaire) may facilitate the early prevention or treatment of those impediments, which, in the end, may help prevent malnutrition, or at least prevent the symptoms from getting worse," the authors state.

The study received no funding. Study coauthor Harriet Jager-Wittenaar, RD, PhD, was co-developer of the PG-SGA-based Pt-Global app/Web tool. De Pinho and the remaining authors have disclosed no relevant financial relationships.

Cancer. Published online September 9, 2019. Abstract

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