Impairment of appetite and associated factors in older adults hospitalized with cancer

Rayne de Almeida Marques Thamirys de Souza Chaves Ribeiro Vanusa Felício de Souza Maria Cláudia Bernardes Spexoto Taísa Sabrina Silva Pereira Valdete Regina Guandalini About the authors

Resumo

Objetivo

Investigar o comprometimento do apetite em pessoas idosas hospitalizadas com câncer e sua associação com estado nutricional e presença de caquexia.

Métodos

Estudo transversal realizado com pessoas idosas de ambos os sexos, diagnosticadas com neoplasia maligna, de julho de 2017 a março de 2019 em um hospital universitário. A amostra final foi composta por 90 pacientes. O comprometimento do apetite foi identificado pelo Questionário de Apetite e Sintomas para Pacientes com Câncer (CASQ) e o estado nutricional pela Avaliação Subjetiva Global Produzida pelo Próprio Paciente (ASG-PPP). A presença de caquexia foi avaliada pela perda de peso >5% nos últimos 6 meses; ou índice de massa corporal (IMC) <20 kg/m22 Noone AM, Howlader N, Krapcho M, Miller D, Brest A, Yu M, et al. SEER Cancer Statistics Review 1975-2015 [Internet]. Betesha; INC; 2018 [acesso em 07 jul. 2020. Disponível em: https://seer.cancer.gov/archive/csr/1975_2015/
https://seer.cancer.gov/archive/csr/1975...
e perda de peso >2%; ou índice de músculo esquelético apendicular consistente com sarcopenia e perda de peso >2%.

Resultados

Houve predomínio de indivíduos do sexo masculino (56,7%), autodeclarados não brancos (56,7%), com tumores localizados no trato gastrointestinal (75,6%) e mediana de idade de 67 anos. 75,6% dos indivíduos apresentaram comprometimento do apetite, 57,8% suspeita de desnutrição ou desnutrição de algum grau, 54,4% caquexia e 92,2% necessidade de intervenção nutricional. Houve associação entre as categorias do CASQ com estado nutricional (p=0,001) e presença de caquexia (p=0,050). Após análise de regressão logística, a desnutrição permaneceu associada ao comprometimento do apetite [OR: 4,68 (IC 95%: 1,50–14,56), p=0,008].

Conclusão

A presença de desnutrição aumentou as chances de comprometimento do apetite, o que reforça a necessidade da triagem e intervenção nutricional precoces, a fim de reduzir e/ou evitar os agravos nutricionais.

Palavras-Chave:
Saúde do Idoso; Câncer; Estado Nutricional; Caquexia; Apetite

Abstract

Objective

To investigate appetite impairment in older adults hospitalized with cancer and its association with nutritional status and cachexia.

Method

A cross-sectional study, conducted with older adults men and women diagnosed with malignant neoplasia from July 2017 to March 2019 at a university hospital. The final sample consisted of 90 patients. Appetite was evaluated using the Cancer Appetite and Symptom Questionnaire (CASQ) and nutritional status was determined using the Patient-Generated Subjective Global Assessment (PG-SGA). Presence of cachexia was assessed by weight loss >5% in the last 6 months; or body mass index (BMI) <20 kg/m22 Noone AM, Howlader N, Krapcho M, Miller D, Brest A, Yu M, et al. SEER Cancer Statistics Review 1975-2015 [Internet]. Betesha; INC; 2018 [acesso em 07 jul. 2020. Disponível em: https://seer.cancer.gov/archive/csr/1975_2015/
https://seer.cancer.gov/archive/csr/1975...
and weight loss >2%; or appendicular skeletal muscle index consistent with sarcopenia and weight loss >2%.

Results

There was a predominance of male (56.7%) self-declared non-white individuals (56.7%), with tumors in the gastrointestinal tract (75.6%) and median age of 67.0 years. 75.6% of the individuals have impaired appetite, 57.8% suspected malnutrition or malnutrition of some degree, 54.4% cachexia and 92.2% needed nutritional intervention. There was significant association between CASQ categories with nutritional status (p= 0.001) and presence of cachexia (p=0.050). After logistic regression analysis, malnutrition remained associated with impaired appetite assessed by CASQ score [OR: 4.68 (CI 95%: 1.50-14.56), p=0.008]

Conclusion

The presence of malnutrition increased the chances of appetite impairment, which reinforces the need for early nutritional screening and intervention, in order to reduce and/or avoid nutritional problems.

Keywords
Health of the Elderly; Cancer; Nutritional Status; Cachexia; Appetite

INTRODUCTION

According to the World Health Organization (WHO), among non-communicable diseases and injuries, cancer has occupied second place in terms of causes of illness and death11 World Health Organization. Noncommunicable diseases country profiles 2018 [Internet]. Geneva; WHO; 2018 [acesso em 05 jul. 2020]. Disponível em: https://apps.who.int/iris/handle/10665/274512
https://apps.who.int/iris/handle/10665/2...
. In older people, the incidence of new cases of cancer is higher than younger individuals, in addition to representing the greatest fatal victims of the disease, particularly those over 65 years of age, representing about 50% of cases and 70% of deaths by malignant neoplasms22 Noone AM, Howlader N, Krapcho M, Miller D, Brest A, Yu M, et al. SEER Cancer Statistics Review 1975-2015 [Internet]. Betesha; INC; 2018 [acesso em 07 jul. 2020. Disponível em: https://seer.cancer.gov/archive/csr/1975_2015/
https://seer.cancer.gov/archive/csr/1975...
.

In this age group, the physiological changes characteristic of aging, such as changes in taste and lean mass reduction, are aggravated by cancer, and contribute to the emergence of malnutrition33 Dent E, Hoogendijk EO, Visvanathan R, Wright ORL. Malnutrition Screening and Assessment in Hospitalised Older People: a review. J Nutr Health Aging. 2019;23(5):431-41.,44 Oliveira LPM, Anunciação TA, da Costa MLV. Estado Nutricional de Idosos Oncológicos por meio de Diferentes Métodos. Rev Bras Cancerol. 2018;64(2):209-15..

Malnutrition can be caused by insufficient energy supply, in addition to inadequate consumption and/or absorption of nutrients, which may or may not be related to inflammation55 Meza-valderrama D, Marco E, Vanesa D, Muns MD, Tejero-s M, Duarte E, et al. Sarcopenia, Malnutrition, and Cachexia: Adapting Definitions and Terminology of Nutritional Disorders in Older People with Cancer. Nutrients. 2021;13(3):1-9.. However, when related to diseases such as cancer, it results mainly from systemic inflammation induced by the tumor, with consequent inappetence, significant loss of body weight and changes in body composition66 Arends J, Baracos V, Bertz H, Bozzetti F, Calder PC, Deutz NEP, et al. ESPEN expert group recommendations for action against cancer- related malnutrition. Clin Nutr. 2017;36(5):1187-96..

In 2015, the Lusa-Brazilian Survey of the Old-aged Oncology Nutrition (INCA)77 Instituto Nacional de Câncer José Alencar Gomes da Silva. Inquérito Luso-Brasileiro de Nutrição Oncológica do Idoso: um estudo multicêntrico [Internet]. Rio de Janeiro; INCA; 2015 [acesso em 10 jul. 2020]. Disponível em: https://www.inca.gov.br/publicacoes/livros/inquerito-luso-brasileiro-de-nutricao-oncologica-do-idoso
https://www.inca.gov.br/publicacoes/livr...
pointed out that 33.2% of older people with cancer were malnourished and 39.8% were at nutritional risk. Previous studies have shown that the prevalence of these changes in older people with cancer ranges from 40% to 60%, associated with nutritional impact symptons (NIS), tumor staging and location, type of treatment and previous nutritional status44 Oliveira LPM, Anunciação TA, da Costa MLV. Estado Nutricional de Idosos Oncológicos por meio de Diferentes Métodos. Rev Bras Cancerol. 2018;64(2):209-15.,88 Santos CA, Ribeiro AQ, Rosa COB, Ribeiro RCL. Depressão, déficit cognitivo e fatores associados à desnutrição em idosos com câncer. Ciênc Saúde Colet. 2015;20(3):751-60..

Older people with cancer and malnutrition are even more vulnerable and are at greater risk of weight loss due to the disease’s aggravations and associated comorbidities, increasing the risk of morbidity and mortality, length of stay, hospital readmissions, susceptibility to infections, reduced functionality and manifestation of cancer cachexia99 Bullock AF, Greenley SL, Mckenzie GAG, Paton LW, Johnson MJ. Relationship between markers of malnutrition and clinical outcomes in older adults with cancer : systematic review, narrative synthesis and meta-analysis. Eur J Clin Nutr. 2020;74(11):1519-35.,1010 Instituto Nacional de Câncer José Alencar Gomes da Silva. Consenso Nacional de Nutrição Oncológica [Internet]. Rio de Janeiro: INCA; 2016 [acesso em 10 jul. 2020. Disponível em: https://www.inca.gov.br/publicacoes/livros/consenso-nacional-de-nutricao-oncologica
https://www.inca.gov.br/publicacoes/livr...
. This, in turn, is another condition commonly observed in older people with cancer and coexisting with malnutrition, which makes the diagnosis and effective and appropriate treatment difficult99 Bullock AF, Greenley SL, Mckenzie GAG, Paton LW, Johnson MJ. Relationship between markers of malnutrition and clinical outcomes in older adults with cancer : systematic review, narrative synthesis and meta-analysis. Eur J Clin Nutr. 2020;74(11):1519-35..

Cancer cachexia is a type of malnutrition with chronic inflammation present and should not be identified as an advanced and final stage of malnutrition, however these diagnostic criteria are still a challenge for professionals and the scientific community55 Meza-valderrama D, Marco E, Vanesa D, Muns MD, Tejero-s M, Duarte E, et al. Sarcopenia, Malnutrition, and Cachexia: Adapting Definitions and Terminology of Nutritional Disorders in Older People with Cancer. Nutrients. 2021;13(3):1-9..

Cachexia is recognized as a multifactorial syndrome characterized by involuntary weight loss, with continuous loss of skeletal muscle mass, with or without loss of fat mass, which cannot be fully reversed by conventional nutritional support that can lead to progressive functional impairment1111 Fearon K, Strasser F, Anker SD, Bosaeus I, Bruera E, Fainsinger RL, et al. Definition and classification of cancer cachexia : an international consensus. Lancet Oncol. 2011;12(5):489-95..

Both malnutrition and cachexia have overlapping clinical presentations and diagnostic criteria, however they differ widely in pathophysiology, etiology, prognosis and therapeutic approaches1111 Fearon K, Strasser F, Anker SD, Bosaeus I, Bruera E, Fainsinger RL, et al. Definition and classification of cancer cachexia : an international consensus. Lancet Oncol. 2011;12(5):489-95.,55 Meza-valderrama D, Marco E, Vanesa D, Muns MD, Tejero-s M, Duarte E, et al. Sarcopenia, Malnutrition, and Cachexia: Adapting Definitions and Terminology of Nutritional Disorders in Older People with Cancer. Nutrients. 2021;13(3):1-9.,99 Bullock AF, Greenley SL, Mckenzie GAG, Paton LW, Johnson MJ. Relationship between markers of malnutrition and clinical outcomes in older adults with cancer : systematic review, narrative synthesis and meta-analysis. Eur J Clin Nutr. 2020;74(11):1519-35.. Malnutrition is specifically associated with the intake and use of nutrients and, therefore, a screening instrument that can also identify impairment in oral food intake becomes necessary99 Bullock AF, Greenley SL, Mckenzie GAG, Paton LW, Johnson MJ. Relationship between markers of malnutrition and clinical outcomes in older adults with cancer : systematic review, narrative synthesis and meta-analysis. Eur J Clin Nutr. 2020;74(11):1519-35..

Reduced food intake is a common condition in malnutrition and cancer cachexia. Even though they can occur at different times, both conditions potentiate progressive weight loss, worsen quality of life, response to treatment and postoperative complications55 Meza-valderrama D, Marco E, Vanesa D, Muns MD, Tejero-s M, Duarte E, et al. Sarcopenia, Malnutrition, and Cachexia: Adapting Definitions and Terminology of Nutritional Disorders in Older People with Cancer. Nutrients. 2021;13(3):1-9.,1212 Martin L, Kubrak C. How much does reduced food intake contribute to cancer-associated weight loss. Curr Opin Support Palliat Care. 2018;12(4):410-9..

People with cancer have a high prevalence of appetite disorders that can significantly impact their nutritional status and quality of life1313 Galindo DEB, Vidal-casariego A, Calleja-fern A, Hernandez-Moreno A, de la Maza BP, Pedraza-Lorenzo M, et al. Appetite disorders in cancer patients : Impact on nutritional status and quality of life. Appetite. 2017;114:23-7.. In older people with cancer, impaired appetite can be even more serious, as it adds to the anorexia of aging, a process characterized by age-related reduced appetite and food intake1414 Sanford AM. Anorexia of aging and its role for frailty. Curr Opin Clin Nutr Metab Care. 2017;20(1):54-60..

Given this scenario and the worsening nutritional status, commonly observed in older people with cancer, this study aimed to investigate the impairment of appetite in older people hospitalized with cancer and its association with nutritional status and the presence of cachexia.

METHOD

This is a cross-sectional, non-probabilistic, convenience sampling study conducted at a tertiary public hospital in Vitória (ES), Brazil. Older people of both sexes, diagnosed with solid tumors (ICD: C00 to C97), determined by the International Classification of Diseases for Oncology (ICD-O)1515 Organização Mundial da Saúde. CID-O Classificação Internacional de Doenças para Oncologia. Geneva: WHO; 1978. and who were admitted for surgical treatment in the Surgical and Reparatory and Internal Medicine Units, from July 2017 to May 2019 participated in the study.

Patients aged ≥60 years old1616 World Health Organization. Health Topics: ageing and Life Course [Internet]. Geneva: WHO; 2017 [acesso em 17 jun. 2020]. Disponível em: http://www.who.int/topics/agein/en/
http://www.who.int/topics/agein/en/ ...
, diagnosed with malignant neoplasm regardless of type and anatomical location, confirmed in medical records, evaluated in the first 48 hours of hospital admission, able to answer the applied instruments, with the possibility of having the anthropometric data measured directly and with the oral route preserved were included. Patients with cognitive and neurological alterations foreseen in the medical record, patients in respiratory isolation, in palliative care, who were using appetite-stimulating drugs, bedridden, in preoperative fasting and who did not present all the information investigated in the study were excluded. After this step, the final sample consisted of 90 older people with cancer.

Data collection took place through interviews by three researchers responsible for the study in the pre-surgical period, using specific protocols. In order to minimize possible sample selection and data collection biases, all researchers were properly trained to apply the instruments and to take anthropometric measurements. Hospitalizations and surgical indications were monitored daily so that all older people during the study period could be considered.

Appetite impairment was the dependent variable assessed. The independent variables investigated were: sociodemographic (age, sex, self-reported race/color), clinical (tumor location) and anthropometric [body mass (kg), height (m)]. As for race/color, this was grouped into whites and non-whites, for those who declared themselves yellow, brown and black1717 Instituto Brasileiro de Geografia e Estatística. Cor ou raça [Internet]. Rio de Janeiro: IBGE; 2019 [acesso em 18 jun. 2020]. Dsponível em: https://cnae.ibge.gov.br/en/component/content/article/95-7a12/7a12-vamos-conhecer-o-brasil/nosso-povo/16049-cor-ou-raca.html
https://cnae.ibge.gov.br/en/component/co...
. Tumor location was obtained from medical records and grouped into two categories: gastrointestinal tract (GIT) - esophagus, stomach, duodenum, colon, rectum, appendix and adnexal glands (pancreas, liver and biliary tract); non-GIT: lung, blood, head and neck, prostate, skin, mediastinum, ovary, chest and pelvis.

For the present study, body mass (kg) and height (m) were directly measured, according to the technique recommended by the WHO1818 World Health Organization. Physical status: the use and interpretation of anthropometry: Report of the WHO Expert Committee [Internet]. Geneva: WHO; 1995 [acesso em 20 jun. 2020]. Disponível em: https://apps.who.int/iris/handle/10665/37003
https://apps.who.int/iris/handle/10665/3...
. Body mass was measured with the aid of a Tanita® tetrapolar bioimpedance scale, with a maximum capacity of 100kg and precision of 100g. To measure height, the AlturExata® portable stadiometer was used, with a bilateral scale in millimeters and a use capacity of 0.35 to 2.13 m. Body mass and height were used to calculate the body mass index (BMI). BMI was calculated by dividing current body mass (kg) by height squared (m).

The assessment of nutritional status was performed from the Patient-Generated Subjective Global Assessment (PG-SGA). The version translated and validated for Brazilian Portuguese by Gonzalez et al.1919 Gonzalez MC, Borges LR, Silveira DH, Assunção MCF, Orlandi SP. Validação da versão em português da avaliação subjetiva global produzida pelo paciente. Rev Bras Nutr Clin. 2010;52(2):102-8., upon permission to use PG-SGA/Pt-Global Platform (www.pt-global.org). The PG-SGA is a subjective nutritional assessment and screening tool, indicated by the Brazilian Consensus on Oncology Nutrition1010 Instituto Nacional de Câncer José Alencar Gomes da Silva. Consenso Nacional de Nutrição Oncológica [Internet]. Rio de Janeiro: INCA; 2016 [acesso em 10 jul. 2020. Disponível em: https://www.inca.gov.br/publicacoes/livros/consenso-nacional-de-nutricao-oncologica
https://www.inca.gov.br/publicacoes/livr...
for the evaluation of cancer patients in Brazil.

The version used is divided into two parts. The first is answered by the patient and comprises questions related to nutritional risk symptoms common in cancer patients, such as functional deficit, weight changes, dietary changes and depression. The second part, completed by the researchers responsible for the study, assesses questions based on factors associated with the presence of metabolic stress (fever and use of corticosteroids), physical depletion (changes in fat reserves, muscle mass and water retention), percentage of weight loss in 1 month or 6 months and the presence of other factors related to the health condition such as cancer, pulmonary or cardiac cachexia, decubitus ulcer, presence of trauma, age over 65 years and acquired immunodeficiency syndrome (AIDS).

The PG-SGA allows classifying nutritional status into three categories: A= well nourished; B= Moderate/suspected malnutrition, C = Severely malnourished. This version also allows assessing the need for nutritional intervention, which is defined through a numerical score, where 0-1 points: no intervention required at this time. Re-assessment on routine and regular basis during treatment. 2-3 Patient & family education by dietitian, nurse, or other clinician with pharmacologic intervention as indicated by symptom survey and lab values as appropriate. 4-8 Requires intervention by dietitian, in conjunction with nurse or physician as indicated by symptoms (Box 3). ≥ 9 Indicates a critical need for improved symptom management and/or nutrient intervention options.

Cachexia was identified according to the criteria defined by the International Consensus on Cachexia1111 Fearon K, Strasser F, Anker SD, Bosaeus I, Bruera E, Fainsinger RL, et al. Definition and classification of cancer cachexia : an international consensus. Lancet Oncol. 2011;12(5):489-95.: weight loss >5% in the last 6 months; or BMI<20 and any degree of weight loss >2%; or appendicular skeletal muscle index consistent with sarcopenia and any degree of weight loss >2%. In this study, all patients diagnosed with cachexia met the first criterion.

The dependent variable, appetite, was evaluated by the Cancer Appetite and Symptom Questionnaire (CASQ) from the translated and validated version for the Brazilian population with cancer2020 Spexoto MCB, Serrano SV, Halliday V, Maroco J, Campos JADB. Cancer Appetite and Symptom Questionnaire (CASQ) for Brazilian Patients : Cross-Cultural Adaptation and Validation Study. PLoS ONE. 2016;11(6):1-10.. The instrument assesses the presence of symptoms related to appetite, namely: presence of appetite; early satiety; lack of appetite; change in taste; pleasure in eating; presence of nausea; mood swings; changes in willingness to perform daily activities and presence of pain. The questions have answers arranged on a five-point Likert scale, with the exception of the question regarding pain, which presents answers ranging up to 6 points, being very mild or no pain, mild, moderate, severe, very severe. It is worth clarifying that four items of the instrument presented the response scale inverted in relation to the others. An equation proposed by Spexoto et al.2020 Spexoto MCB, Serrano SV, Halliday V, Maroco J, Campos JADB. Cancer Appetite and Symptom Questionnaire (CASQ) for Brazilian Patients : Cross-Cultural Adaptation and Validation Study. PLoS ONE. 2016;11(6):1-10. in order to generate a global score, which classifies the impairment of appetite into three categories: low (≤1 point); moderate (1–3 points) and severe (>3 points), for the present study, moderate and severe impairment were grouped.

A descriptive analysis expressed as median and percentiles was performed to describe continuous variables and absolute and relative frequency for categorical variables. The Kolmogorov-Smirnov test was used to verify the normality of quantitative variables. Only individuals with all data were included in the analysis, with no treatment for missing data.

To verify the association of proportions between nutritional status, the presence of cachexia and the need for nutritional intervention with the CASQ categories, Fisher’s exact test or the chi-square test was used. For binary logistic regression, the PG-SGA categories B and C and the CASQ categories, moderate impairment and severe impairment, were grouped.

To determine the influence of the variables on appetite impairment identified by the CASQ (dependent variable) binary logistic regression analysis was used. The crude Odds Ratio (OR) was presented and after adjustments for sociodemographic variables. The adjustment variables were inserted in blocks: model 1: age and sex and model 2: age, sex and tumor location. The variables that presented p≤0.05 in the previous tests were included in the regression. The significance level adopted was p≤0.05 for all tests.

This study was approved by the Ethics and Research Committee of the Federal University of Espírito Santo, under number 2,141,932. All patients signed the Free Informed Consent Form (FICF), following resolutions 510/2016 and 466/12 of the National Health Council, which regulate research with human beings.

RESULTS

Table 1 shows the sociodemographic and clinical characteristics of older people hospitalized with cancer. 90 older people participated in the study, with a median age of 67.0 years, minimum age of 60 years and maximum of 88 years.

Table 1
Demographic and clinical characteristics of older people hospitalized with cancer (n=90). Vitória (ES), 2019.

The diagnosis of nutritional status, the need for nutritional intervention obtained by the PG-SGA, the presence of cachexia and the impairment of appetite, identified by the CASQ are shown in Table 2.

Table 2
Nutritional status, need for nutritional intervention, presence of cachexia and impaired appetite in older people hospitalized with cancer (n=90). Vitória (ES), 2019.

Table 3 shows the difference between the CASQ categories and nutritional status, presence of cachexia, need for nutritional intervention and tumor location. Malnourished older people were those with moderate and severe impairment of appetite (p=0.005), the same occurring for older people with cachexia (p=0.050).

Table 3
Nutritional status, presence of cachexia, need for nutritional intervention, and tumor location according to CASQ classifications in older people hospitalized with cancer (n=90). Vitória (ES), 2019.

Table 4 shows the results of the binary logistic regression models. Significant associations were found between impaired appetite, according to the CASQ, and malnutrition, even after adjusting for age, sex and tumor location. Older people with suspected malnutrition or malnourished were 4.68 times more likely to have their appetite compromised when compared to well-nourished older people [OR: 4.68 (95% CI: 1.50–14.56) p=0.008].

Table 4
Association between the categories of appetite impairment, according to CASQ and nutritional status after crude and adjusted binary logistic regression analysis in older people hospitalized with cancer (n=90). Vitória (ES), 2019.

DISCUSSION

This study showed that malnutrition increased the chances of impaired appetite in older people hospitalized with cancer. An even higher proportion of malnutrition, cachexia, need for critical nutritional intervention and symptom control, and moderate to severe appetite impairment were observed.

Brazilian Enquiry on Oncology Nutrition (INCA)2121 Instituto Nacional do Câncer José Alencar Gomes da Silva. Inquérito Brasileiro de Nutrição Oncológica [Internet]. Rio de Janeiro: INCA; 2013 [acesso em 17 ago. 2020]. Disponível em: https://www.inca.gov.br/publicacoes/livros/inquerito-brasileiro-de-nutricao-oncologica
https://www.inca.gov.br/publicacoes/livr...
evaluated, with the same instrument, cancer patients from 45 Brazilian institutions, and found that 55.6% of the population over 65 years of age was malnourished or at nutritional risk. Other studies that evaluated older people with cancer using the PG-SGA found a prevalence of malnutrition between 60.4% and 78.7%, showing the greater vulnerability of this population2222 Barao K, Abe M, Cavagnari V, Fucuta PS, Forones NM. Association Between Nutrition Status and Survival in Elderly Patients With Colorectal Cancer. Nutr Clin Pract. 2017;32(5):658-63.,2323 Dubhashi SP, Kayal A. Preoperative nutritional assessment in elderly cancer patients undergoing elective surgery: MNA or PG-SGA? Indian J Surg. 2015;77(2):232-5.. This tool has been considered a prognostic and comprehensive factor in the identification of nutritional status in older people with cancer, as it more extensively assesses weight changes, nutritional impact symptoms (NIS) and the need for nutritional intervention2222 Barao K, Abe M, Cavagnari V, Fucuta PS, Forones NM. Association Between Nutrition Status and Survival in Elderly Patients With Colorectal Cancer. Nutr Clin Pract. 2017;32(5):658-63.,2323 Dubhashi SP, Kayal A. Preoperative nutritional assessment in elderly cancer patients undergoing elective surgery: MNA or PG-SGA? Indian J Surg. 2015;77(2):232-5..

Another risk factor for malnutrition may be related to the location of the cancer in the GIT2424 Alkan SB, Artaç M. The relationship between nutritional status and handgrip strength in adult cancer patients: a cross-sectional study. Support Care Cancer. 2018;26(7):2441-51., and which was in greater proportion in this study. Tumors located in the GIT directly impact the process of ingestion, digestion and absorption of nutrients, such as the presence of obstructive tumors, dysphagia, odynophagia and vomiting, often associated with cancer, which will compromise food intake and, consequently, the nutritional status2424 Alkan SB, Artaç M. The relationship between nutritional status and handgrip strength in adult cancer patients: a cross-sectional study. Support Care Cancer. 2018;26(7):2441-51.,2525 Vieira AR, Fortes RC. Qualidade de vida em pacientes com câncer do trato gastrointestinal: uma revisão de literatura. Com Ciênc Saúde. 2015;26(1/2):45-56..

A cross-sectional study carried out in Brazil that evaluated patients with cancer in the GIT treated surgically showed that 63% of patients with tumors located in the upper GIT showed changes in appetite and 60% had compromised food intake2626 Barreiro TD, Saueressig MG, Kabke GB, Ferreira PK, Fruchtenicht AVG, Corleta OC, et al. Score of “eat-ability” as a predictor of malnutrition in patients with gastrointestinal tract cancer: a pilot study. Nutr Hosp. 2018;35:633-41.. For those with tumors in the lower GIT, the prevalences were 45% and 36%, respectively.2626 Barreiro TD, Saueressig MG, Kabke GB, Ferreira PK, Fruchtenicht AVG, Corleta OC, et al. Score of “eat-ability” as a predictor of malnutrition in patients with gastrointestinal tract cancer: a pilot study. Nutr Hosp. 2018;35:633-41.. Also in this study, it was observed that 46.3% of the patients were severely malnourished and 29.3% were suspected of being malnourished or moderately malnourished2626 Barreiro TD, Saueressig MG, Kabke GB, Ferreira PK, Fruchtenicht AVG, Corleta OC, et al. Score of “eat-ability” as a predictor of malnutrition in patients with gastrointestinal tract cancer: a pilot study. Nutr Hosp. 2018;35:633-41..

The high prevalence of changes in appetite and food intake, and the prevalence of severe malnutrition in these patients, demonstrate the relevance of considering the location of the tumor on the nutritional status, especially when located in the GIT, so that clinical and nutritional managements are implemented early, in order to reduce and/or avoid these scenarios. Malnutrition can further compromise appetite in this population, which already has suppressed physiological responses, and potentiate the consequences of the disease and malnutrition itself.

Faced with an impaired nutritional status, the high need for critical nutritional intervention was another outcome observed in this study. A previous study carried out in the same hospital in 2016 showed that 91.4% of the patients evaluated had a need for critical nutritional intervention upon hospital admission, showing that this is a common condition in these patients2727 Teixeira C, Mariani C, Gabriella M, Toniato S, Valente P, Petarli B, et al. Escore da Avaliação Subjetiva Global Produzida pelo Próprio Paciente: identificação do risco e necessidade de intervenção nutricional em pacientes com câncer na admissão hospitalar. Nutr Clín Diet Hosp. 2018;38(4):95-102..

Dos Santos et al.2828 dos Santos CA, Rosa COB, Ribeiro AQ, Ribeiro RCL. Patient-Generated Subjective Global Assessment and classic anthropometry: comparison between the methods in detection of malnutrition among elderly with cancer. Nutr Hosp. 2015;31(1):384-92. when comparing the nutritional diagnosis obtained by the PG-SGA with objective anthropometric measures in older people undergoing anticancer treatment, they found that higher values of the PG-SGA score, which indicate the need for nutritional intervention, were associated with reduced food intake and lower anthropometric measurements related to body mass, muscle tissue and fat reserves. The PG-SGA score has been used in nutritional assessment because it has a high degree of reproducibility, sensitivity and specificity when compared to other validated methods2727 Teixeira C, Mariani C, Gabriella M, Toniato S, Valente P, Petarli B, et al. Escore da Avaliação Subjetiva Global Produzida pelo Próprio Paciente: identificação do risco e necessidade de intervenção nutricional em pacientes com câncer na admissão hospitalar. Nutr Clín Diet Hosp. 2018;38(4):95-102..

The presence of cachexia was observed in more than half of the older people evaluated. Lima et al.2929 Lima KS, da Luz MCL, Campos M, de Araújo AO, Lima KS, Burgos MGPA, et al. Caquexia e pré-caquexia em pacientes com câncer do trato gastrointestinal. Nutr Clín Diet Hosp. 2017;37(4):101-7. verified the frequency of cancer-related cachexia in patients with tumors in the GIT and found a prevalence of 56.3%. Specifically in older people with cancer, Dunne et al.3030 Dunne RF, Roussel B, Culakova E, Pandya C, Fleming FJ, Hensley B, et al. Characterizing cancer cachexia in the geriatric oncology population. J Geriatr Oncol. 2019;10(3):415-9. identified that 65.0% of the geriatric cancer population assessed in their study had cachexia. In this age group and with cancer, the risk of developing cachexia may be even higher, due to the changes inherent to aging that contribute to the worsening of the nutritional status, as discussed above1010 Instituto Nacional de Câncer José Alencar Gomes da Silva. Consenso Nacional de Nutrição Oncológica [Internet]. Rio de Janeiro: INCA; 2016 [acesso em 10 jul. 2020. Disponível em: https://www.inca.gov.br/publicacoes/livros/consenso-nacional-de-nutricao-oncologica
https://www.inca.gov.br/publicacoes/livr...
, which reinforces the importance of considering it in the screening and initial nutritional assessment, especially in the hospital environment.

Another change that is also little considered in the evaluation of older people, especially with cancer, is the impairment of appetite, which was identified in most of the older people evaluated. Studies that evaluated the loss of appetite in individuals with cancer found that this condition is more frequent in older people and is more present with advancing age3131 Inomata M, Shimokawa K, Tokui K, Taka C, Okazawa S, Kambara K, et al. Appetite Loss as an Adverse Effect During Treatment with EGFR-TKIs in Elderly Patients with Non-small Cell Lung Cancer. Anticancer Res. 2016;36(9):4951-4.,3232 de Pinho NB, Martucci RB, Rodrigues VD, D’Almeida CA, Thuler LCS, Saunders C, et al. High Prevalence of Malnutrition and Nutrition Impact Symptoms in Older Patients With Cancer: Results of a Brazilian Multicenter Study Cancer. 2020;126(1):156-64..

Decreased food intake is a symptom frequently observed in cancer patients, and is associated with several metabolic changes originated or resulting from the tumor2626 Barreiro TD, Saueressig MG, Kabke GB, Ferreira PK, Fruchtenicht AVG, Corleta OC, et al. Score of “eat-ability” as a predictor of malnutrition in patients with gastrointestinal tract cancer: a pilot study. Nutr Hosp. 2018;35:633-41.. These changes are mediated by several factors that modulate central nervous system receptors and neurons, especially cytokines, released by the immune system and the tumor3333 Hariyanto TI, Kurniawan A. Appetite problem in cancer patients: Pathophysiology, diagnosis, and treatment. Cancer Treat Res Commun. 2021;27:1-10.. These substances, such as IL-1, IL-6, TNF-α and IFNγ, can induce anorexia by antagonizing the action of Neuropeptide Y (NPY) in the hypothalamus, inducing the release of corticotropin releasing factor (CRF), a potent anorectic factor and modulate significant changes in the α-subunits of the ventromedial nucleus (VMN) G protein, which participate in the control of food intake3333 Hariyanto TI, Kurniawan A. Appetite problem in cancer patients: Pathophysiology, diagnosis, and treatment. Cancer Treat Res Commun. 2021;27:1-10..

Antineoplastic therapies and related symptoms also interfere with the maintenance of appetite and nutritional status, as they can affect the perception of smell and taste and interfere with patients’ ability to consume and digest food2626 Barreiro TD, Saueressig MG, Kabke GB, Ferreira PK, Fruchtenicht AVG, Corleta OC, et al. Score of “eat-ability” as a predictor of malnutrition in patients with gastrointestinal tract cancer: a pilot study. Nutr Hosp. 2018;35:633-41..

Thus, it is observed that the processes that lead to impaired appetite, malnutrition and cancer-related cachexia are integrated, and that generally result mainly from systemic inflammation and adverse effects of treatment.

In the studied sample, it was evidenced that patients with cancer cachexia had greater appetite impairment. When evaluating the presence of cachexia, loss of appetite and anorexia are factors that should be considered, and are associated with weight loss and exacerbation of this syndrome1111 Fearon K, Strasser F, Anker SD, Bosaeus I, Bruera E, Fainsinger RL, et al. Definition and classification of cancer cachexia : an international consensus. Lancet Oncol. 2011;12(5):489-95.. The CASQ is a predictor of weight loss, therefore, it can early identify the risk of developing cachexia2020 Spexoto MCB, Serrano SV, Halliday V, Maroco J, Campos JADB. Cancer Appetite and Symptom Questionnaire (CASQ) for Brazilian Patients : Cross-Cultural Adaptation and Validation Study. PLoS ONE. 2016;11(6):1-10..

Another significant association found was between impaired appetite and malnutrition, which was confirmed after binary logistic regression analysis. Reduced appetite and food intake are often associated with malnutrition, especially in patients with GIT cancer3434 Zhang X, Pang L, Sharma S V, Li R, Nyitray AG, Edwards BJ. Prevalence and factors associated with malnutrition in older patients with cancer. J Geriatr Oncol. 2019;10(5):763-9., however the causal relationship can only be defined in longitudinal studies.

De Pinho et al.3535 de Pinho NB, Martucci RB, Rodrigues VB, D’Almeida CA, Thuler LCS, Saunders C, et al. Malnutrition associated with nutritional impact symptoms and localization of the disease : Results of a multicentric research on oncological nutrition. Clin Nutr. 2019;38(3):1274-9. evaluated the relationship between PG-SGA-diagnosed malnutrition and NIS in cancer patients, and identified that swallowing problems, loss of appetite, vomiting, and the presence of more than three NIS were independent factors associated with malnutrition. The high frequency of NIS contributes to reduced food intake, worsening the patient’s nutritional status3535 de Pinho NB, Martucci RB, Rodrigues VB, D’Almeida CA, Thuler LCS, Saunders C, et al. Malnutrition associated with nutritional impact symptoms and localization of the disease : Results of a multicentric research on oncological nutrition. Clin Nutr. 2019;38(3):1274-9..

Finally, it is necessary to reaffirm that malnutrition significantly compromises the physiological and metabolic responses of individuals, with even greater damage to older people with cancer, including appetite. Thus, our results point to the need for nutritional screening in order to prevent and/or reduce the impact of malnutrition in this population.

Although lack of appetite is one of the characteristics of cancer cachexia, this study found no association between the presence of cachexia and impaired appetite after adjusted logistic regression analysis. A possible explanation for this result may be the fact that a predominance of moderate appetite impairment was observed, which still does not characterize anorexia itself, a common condition in cachexia. It is believed that the observed impairment of appetite is more related to anorexia of aging than the presence of cachexia1414 Sanford AM. Anorexia of aging and its role for frailty. Curr Opin Clin Nutr Metab Care. 2017;20(1):54-60.. Another point to consider is that the diagnosis of cachexia in this study was defined by the percentage of weight loss over time and did not consider appetite as one of the criteria. Furthermore, anorexia is not a condition implicit in cachexia, especially in its onset. However, the design of this study does not allow us to assess this causality.

As a contribution, this study used a validated and specific tool to assess appetite in cancer patients that is easy to apply in clinical practice. It also demonstrates the relevance of appetite disorders and the presence of malnutrition and cachexia in older people with cancer, themes little explored in this population. The results also indicate the importance of diagnosing malnutrition and impaired appetite as a way to provide individualized nutritional counseling to manage the complications inherent in both situations. Multimodal clinical treatment is an indicated strategy that must be implemented and guaranteed in the care of older people with cancer.

Among the limitations of this study is its cross-sectional nature, which does not allow determining causal relationships, the absence of information on tumor staging and absence/presence of metastasis, since this is a reference hospital for surgical treatment and this information does not appear in the medical record. Another limitation refers to the fact that this study was carried out in a single public hospital with specific characteristics, which prevents the extrapolation of our results. However, the assessments and instruments were carefully applied by a small trained team.

CONCLUSION

Older people hospitalized with cancer had a high prevalence of malnutrition, cachexia, impaired appetite and the need for critical nutritional intervention. The presence of malnutrition increased the chances of appetite impairment in the studied population, which reinforces the need for early nutritional screening and intervention, especially in this population, in order to reduce and/or avoid nutritional problems.

  • No funding was received in relation to the present study.

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Publication Dates

  • Publication in this collection
    11 Aug 2021
  • Date of issue
    2021

History

  • Received
    29 Nov 2020
  • Accepted
    28 June 2021
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