ABSTRACT
Patients with gastrointestinal cancer and malnutrition are less likely to tolerate major surgical procedures, radiotherapy or chemotherapy. In general, they display a higher incidence of complications such as infection, dehiscence and sepsis, which increases the length of stay and risk of death, and reduces quality of life. The aim of this review is to discuss the pros and cons of different points of view to assess nutritional risk in patients with gastrointestinal tract (GIT) tumors and their viability, considering the current understanding and screening approaches in the field. A better combination of anthropometric, laboratory and subjective evaluations is needed in patients with GIT cancer, since malnutrition in these patients is usually much more severe than in those patients with tumors at sites other than the GIT.
Keywords:
Nutrition Assessment; Gastrointestinal Tract; Malnutrition; Prognosis; Morbidity.
RESUMO
Pacientes com neoplasia gastrointestinal e desnutridos são menos propensos a tolerar procedimentos cirúrgicos de grande porte, radioterapia ou quimioterapia. Em geral, apresentam maior incidência de complicações, como infecção, deiscência e sepse, o que aumenta o tempo de internação e o risco de morte, e reduz a qualidade de vida. O objetivo desta revisão é abordar os prós e contras de diferentes pontos de vista que avaliam risco nutricional em pacientes com tumores do Trato Gastrointestinal (TGI) e sua viabilidade, considerando o atual entendimento e abordagens de triagem neste campo. Melhor combinação de avaliações antropométricas, laboratoriais e subjetivas se faz necessária em pacientes com câncer do TGI, uma vez que a desnutrição nestes pacientes costuma ser muito mais grave do que naqueles indivíduos com tumores em outros sítios que não o TGI.
Descritores:
Avaliação Nutricional; Trato Gastrointestinal; Desnutrição; Prognóstico; Morbidade.
INTRODUCTION
Currently, cancer is a major public health problem worldwide11. Bray F, Ren JS, Masuyer E, Ferlay J. Global estimates of cancer prevalence for 27 sites in the adult population in 2008. Int J Cancer. 2013;132(5):1133-45.. In addition, malnutrition and subsequent weight loss have long been among the leading causes of morbidity and mortality, as well as increased costs with other organs dysfunction associated to cancer patients undergoing surgery22. Van Cutsem E, Arends J. The causes and consequences of cancer-associated malnutrition. Eur J Oncol Nur. 2005;9 Suppl 2:S51-63.. Malnutrition is defined as the energy, protein and other specific nutrients deficient state, which significantly modifies organic functions33. Ryu SW, Kim IH. Comparison of different nutritional assessment in detecting malnutrition among gastric cancer patients. World J Gastroenterol. 2010;16(26):3310-7..
Patients with gastrointestinal malignancy undergoing major elective procedures have a higher risk of postoperative complications and alterations resulting from their pre and post-admission nutritional status, particularly related to surgical stress, immune suppression induced by cancer or by blood transfusion. Among these factors, malnutrition is the most important due to its high prevalence and negative impact on clinical outcomes such as longer hospital stay33. Ryu SW, Kim IH. Comparison of different nutritional assessment in detecting malnutrition among gastric cancer patients. World J Gastroenterol. 2010;16(26):3310-7. and mortality. The latter is much more related to malnutrition than cancer alone and can occur in 20% of cases44. Sungurtekin H, Sungurtekin U, Balci C, Zencir M. Erdem E. The influence of nutritional status on complications after major intraabdominal surgery. J Am Coll Nutr. 2004;23(3):227-32.. Approximately half of the patients with malignancies has malnutrition, and in the case of gastrointestinal tract (GIT) tumors, the mortality rate varies from 30% to 50%, reaching 80% in cases of advanced pancreatic cancer44. Sungurtekin H, Sungurtekin U, Balci C, Zencir M. Erdem E. The influence of nutritional status on complications after major intraabdominal surgery. J Am Coll Nutr. 2004;23(3):227-32.,55. Petroniau A, Alberti LR, Zac RI, Andrade Júnior JCCG. Influência do trauma cirúrgico na concentração sérica de albumina no pós-operatório imediato. Rev Col Bras Cir. 2004;31(3):194-9..
Several nutritional assessment methods can be used55. Petroniau A, Alberti LR, Zac RI, Andrade Júnior JCCG. Influência do trauma cirúrgico na concentração sérica de albumina no pós-operatório imediato. Rev Col Bras Cir. 2004;31(3):194-9., and must be sensitive enough to early identify changes according to specific nutritional imbalances. The method choice depends on the purpose of the assessment, prognosis or even on the response to nutritional interventions22. Van Cutsem E, Arends J. The causes and consequences of cancer-associated malnutrition. Eur J Oncol Nur. 2005;9 Suppl 2:S51-63.,44. Sungurtekin H, Sungurtekin U, Balci C, Zencir M. Erdem E. The influence of nutritional status on complications after major intraabdominal surgery. J Am Coll Nutr. 2004;23(3):227-32..
However, health professionals find it difficult to use most of the currently validated tools for nutritional assessment, due to limited time, method reproducibility, organization or cost66. Ottery FD. Definition of standardized nutritional assessment and interventional pathways in oncology. Nutrition. 1996;12(1 Suppl):S15-9.
7. Barbosa-Silva MCG, Barros AJD. Avaliação nutricional subjetic a: Parte 2 - Revisão de suas adaptações e utilizações nas diverss especialidade clínicas. Arq Gastroenterol. 2002;39(4):248-52.-88. Poziomyck AK, Weston AC, Lameu EB, Cassol OS, Coelho LJ, Moreira LF. Preoperative nutritional assessment and prognosis in patients with foregut tumors. Nutr Cancer. 2012;64(8):1174-81.. Thus, all currently considered parameters show some sort of limitation to accurately assess the state nutritional66. Ottery FD. Definition of standardized nutritional assessment and interventional pathways in oncology. Nutrition. 1996;12(1 Suppl):S15-9.. In the absence of a gold standard, the option for the assessment tool and nutritional classification will depend on the institution and the target population in question, as well as on the resources available88. Poziomyck AK, Weston AC, Lameu EB, Cassol OS, Coelho LJ, Moreira LF. Preoperative nutritional assessment and prognosis in patients with foregut tumors. Nutr Cancer. 2012;64(8):1174-81.
9. Kyle UG, Bosaeus I, De Lorenzo AD, Deurenbergd P, Elia M, Gómez JM, et al. Bioelectrical impedance analysis--part I: review of principles and methods. Clin Nutr. 2004;23(5):1226-43.-1010. Hall JC. Nutritional assessment of surgery patients. J Am Coll Surg. 2006;202(5):837-43.. Although the use of indices and multivariate scores is often regarded as the solution to the lack of standardized and reliable evaluation, this is only a possibility1010. Hall JC. Nutritional assessment of surgery patients. J Am Coll Surg. 2006;202(5):837-43..
Therefore, in the daily practice of oncology, the definition of an appreciable and simple to apply nutritional assessment tool is necessary to identify nutritional risk patients and thus determine the best approach and appropriate nutritional support88. Poziomyck AK, Weston AC, Lameu EB, Cassol OS, Coelho LJ, Moreira LF. Preoperative nutritional assessment and prognosis in patients with foregut tumors. Nutr Cancer. 2012;64(8):1174-81.. The objective of this review is to present an overview of the methods and tools used to determine nutritional risk, considering the pros and cons when applied to patients with GIT cancer.
METHODS
We systematically identified studies on nutritional status of patients with GIT cancer through the PubMed and MEDLINE databases. We researched articles published in the last ten years by combining the terms "nutritional assessment", "GI cancer", "gastrointestinal tract", "gastric cancer", "oesophageal cancer" and "pancreatic cancer". We considered for evaluation only complete articles with those terms in English or Portuguese. We identified additional articles from citations in the articles evaluated.
RESULTS AND DISCUSSION
General review of nutritional assessment
It was in the 1950s that authors first published research related to nutritional assessment procedures. Between 1960 and 1980, malnutrition markers have emerged to evaluate surgical patients and new concepts and nutritional assessment methods have been developed1111. Sando K, Okada A. History of progress in nutritional assessment. Nihon Geka Gakkai Zasshi. 1998;99(3):144-53.. In the following decades, the researchers analyzed the relevance of functional indices and combinations of clinical and laboratory parameters existing in an attempt to better predict nutritional risk. A new concept of body composition was defined from the use of new and more complex equipment and methods of assessment, but still considering subjective concepts77. Barbosa-Silva MCG, Barros AJD. Avaliação nutricional subjetic a: Parte 2 - Revisão de suas adaptações e utilizações nas diverss especialidade clínicas. Arq Gastroenterol. 2002;39(4):248-52.. From the beginning of this century, attempts have been made to demonstrate the nutritional assessment method that would be more accurate and reliable for certain types of patients or specific clinical conditions33. Ryu SW, Kim IH. Comparison of different nutritional assessment in detecting malnutrition among gastric cancer patients. World J Gastroenterol. 2010;16(26):3310-7.,88. Poziomyck AK, Weston AC, Lameu EB, Cassol OS, Coelho LJ, Moreira LF. Preoperative nutritional assessment and prognosis in patients with foregut tumors. Nutr Cancer. 2012;64(8):1174-81..
Subjective methods
In 1980, Detsky et al. described the Subjective Global Assessment (SGA) used to assess preoperative patients with GIT tumors (n = 202) undergoing major surgical procedures; They have shown that SGA could be easily applied and considered it a valid and reliable method to estimate the surgical patients' nutritional status1212. Detsky AS, McLaughlin JR, Baker JP, Johnston N, Whittaker S, Mendelson RA, et al. What is subjective global assessment of nutritional status? JPEN J Parenter Enteral Nutr. 1987;11(1):8-13..
Other authors have published several articles supporting the SGA in determining nutritional status, which differed from other methods in considering not only changes in body composition, but also functional changes. In addition, SGA is a simple, inexpensive, non-invasive method and can be performed at bedside. Correct guidance on the SGA application is essential, since its accuracy depends on the observer's ability to detect subjectively significant nutritional changes88. Poziomyck AK, Weston AC, Lameu EB, Cassol OS, Coelho LJ, Moreira LF. Preoperative nutritional assessment and prognosis in patients with foregut tumors. Nutr Cancer. 2012;64(8):1174-81.,1313. Barbosa-Silva MC, Barros AJ. Indications and limitations of the use of subjective global assessment in clinical practice: an update. Curr Opin Clin Nutr Metab Care. 2006;9(3):263-9.,1414. Lameu EB, Poziomyck AK, Moreira LF, Consequences of malnutrition in the surgical patient. In: Campos ACL, editor. The Treaty of Nutrition and Metabolism in Surgery. Rio de Janeiro: Rubio; 2013. p. 55-64..
Subsequently, the SGA has undergone modifications and adaptations developed specifically to meet the oncological patient characteristics. Questions about symptoms of nutritional impact and resulting from the tumor itself or from the imposed treatment88. Poziomyck AK, Weston AC, Lameu EB, Cassol OS, Coelho LJ, Moreira LF. Preoperative nutritional assessment and prognosis in patients with foregut tumors. Nutr Cancer. 2012;64(8):1174-81. were included and answered by the patient, becoming known as the Patient-generated SGA (PG-SGA). The main introduced difference was a numerical score that allows to better identify patients at nutritional risk and estimate the time required for re-evaluation.
In some multi-center studies on nutritional assessment of hospitalized patients using SGA, different results have been reported, particularly in patients with GIT cancer. Poziomyck et al. found 66% of malnourished patients in surgical cases of upper GIT tumors88. Poziomyck AK, Weston AC, Lameu EB, Cassol OS, Coelho LJ, Moreira LF. Preoperative nutritional assessment and prognosis in patients with foregut tumors. Nutr Cancer. 2012;64(8):1174-81., while Bragagnolo et al. showed 77% of malnourished patients in a similar sample1515. Bragagnolo R, Caporossi FS, Dock-Nascimento DB, Aguilar-Nascimento JE. Espessura do músculo adutor do polegar: um método rápído e confiável na avaliação nutricional de pacients cirúrgicos. Rev Col Bras Cir. 2009;36(5):371-6..
In another study involving 80 patients with GIT tumors, mainly colorectal, Cid Conde et al. found 50% of malnutrition by SGA1616. Cid Conde L, Fernández López T, Neira Blanco P, Arias Delgado J, Varela Correa JJ, Gómez Lorenzo FF. Hyponutrition prevalence among patients with digestive neoplasm before surgery. Nutr Hosp. 2008;23(1):46-53., a result that were higher (70%) in another study with a similar sample1717. Read JA, Crockett N, Volker DH, MacLennan P, Choy ST, Beale P, et al. Nutritional assessment in cancer: comparing the Mini-Nutritional Assessment (MNA) with the scored Patient-Generated Subjective Global Assessment (PGSGA). Nutr Cancer. 2005;53(1):51-6..
Wu et al. had higher incidence of complications and longer hospital stay the worse the level of SGA in patients undergoing major procedures for GIT cancer (mainly gastric)1818. Wu BW, Yin T, Cao WX, Gu ZD, Wang XJ, Yan M, et al. Clinical application of subjective global assessment in Chinese patients with gastrintestinal cancer. World J Gastroenterol. 2009;15(28):3542-9.. These results were also supported by our series of patients with esophageal, stomach and pancreas tumors88. Poziomyck AK, Weston AC, Lameu EB, Cassol OS, Coelho LJ, Moreira LF. Preoperative nutritional assessment and prognosis in patients with foregut tumors. Nutr Cancer. 2012;64(8):1174-81.. Moreover, in patients with esophageal or stomach cancer, SGA appears to be associated with the Glasgow Prognostic score (GPS)1919. Maurício SF, da Silva JB, Bering T, Correia MI. Relationship between nutritional status and the Glasgow Prognostic Score in patients with colorectal cancer. Nutrition. 2013;29(4):625-9.. A study comparing PG-SGA with the Mini Nutritional Assessment (MNA) revealed that these tools seem appropriate to define elderly patients as malnourished1010. Hall JC. Nutritional assessment of surgery patients. J Am Coll Surg. 2006;202(5):837-43.. GPS and MNA concepts are described in Score Methods later in the text.
Anthropometric methods
The accuracy and reproducibility of anthropometric measurements may be affected by the equipment calibration, examiner and parameters used for the predictive equations2020. Lameu EB, Gerude MF, Corrêa RC, Lima KA. Adductor policis muscle: a new anthropometric parameter. Rev Hosp Clin. 2004;59(2):57-62.. Several essentially objective nutritional assessment tools have been used in clinical practice, each with its own characteristics1313. Barbosa-Silva MC, Barros AJ. Indications and limitations of the use of subjective global assessment in clinical practice: an update. Curr Opin Clin Nutr Metab Care. 2006;9(3):263-9..
Body weight is as simple and commonly used measure in clinical practice. However, it does not discriminate mass from fat, muscle, bone or extracellular fluids. Thus, it must be used with caution, since sharp alterations may reflect changes in hydration status, and not necessarily change in cell mass2121. Barbosa-Silva MC. Subjective and objective nutritional assessment methods: what do they really assess? Curr Opin Clin Nutr Metab Care. 2008;11(3):248-54..
Renehan et al. demonstrated that increased body mass index (BMI) on the order of 5 kg/m22. Van Cutsem E, Arends J. The causes and consequences of cancer-associated malnutrition. Eur J Oncol Nur. 2005;9 Suppl 2:S51-63. in both genders was strongly associated with esophageal adenocarcinoma2222. Renehan AG, Tyson M, Egger M, Heller RF, Zwahlen M. Body-mass index and incidence of cancer: a systematic review and meta-analysis of prospective observational studies. Lancet. 2008;371(9612):569-78.. Excess weight, visceral fat and abdominal obesity appears to be more disturbing than subcutaneous fat, and any further increase in BMI confers increased risk of developing colorectal cancer1919. Maurício SF, da Silva JB, Bering T, Correia MI. Relationship between nutritional status and the Glasgow Prognostic Score in patients with colorectal cancer. Nutrition. 2013;29(4):625-9., which, however, has not been confirmed in other studies with this tool88. Poziomyck AK, Weston AC, Lameu EB, Cassol OS, Coelho LJ, Moreira LF. Preoperative nutritional assessment and prognosis in patients with foregut tumors. Nutr Cancer. 2012;64(8):1174-81.,1515. Bragagnolo R, Caporossi FS, Dock-Nascimento DB, Aguilar-Nascimento JE. Espessura do músculo adutor do polegar: um método rápído e confiável na avaliação nutricional de pacients cirúrgicos. Rev Col Bras Cir. 2009;36(5):371-6..
Functional markers are of particular importance, since they correlate well with clinical complications2020. Lameu EB, Gerude MF, Corrêa RC, Lima KA. Adductor policis muscle: a new anthropometric parameter. Rev Hosp Clin. 2004;59(2):57-62.. They may be more sensitive and relevant indicators of changes in nutritional state or response to additional support in the short term than conventional methods88. Poziomyck AK, Weston AC, Lameu EB, Cassol OS, Coelho LJ, Moreira LF. Preoperative nutritional assessment and prognosis in patients with foregut tumors. Nutr Cancer. 2012;64(8):1174-81.. Loss of muscle function is indicative of malnutrition, particularly the loss of lean body mass. Usually expressed by the handgrip strength, it is important to determine the function and the ability of skeletal muscle. The authors consider this as evidence of compromised nutritional status as responsible for the loss of skeletal muscle function and, consequently, loss of handgrip strength88. Poziomyck AK, Weston AC, Lameu EB, Cassol OS, Coelho LJ, Moreira LF. Preoperative nutritional assessment and prognosis in patients with foregut tumors. Nutr Cancer. 2012;64(8):1174-81.,1515. Bragagnolo R, Caporossi FS, Dock-Nascimento DB, Aguilar-Nascimento JE. Espessura do músculo adutor do polegar: um método rápído e confiável na avaliação nutricional de pacients cirúrgicos. Rev Col Bras Cir. 2009;36(5):371-6.,2020. Lameu EB, Gerude MF, Corrêa RC, Lima KA. Adductor policis muscle: a new anthropometric parameter. Rev Hosp Clin. 2004;59(2):57-62.. Recently, the measurement of the thickness of the adductor pollicis muscle (APM) was standardized to anthropometric parameters relating to age, gender and physique88. Poziomyck AK, Weston AC, Lameu EB, Cassol OS, Coelho LJ, Moreira LF. Preoperative nutritional assessment and prognosis in patients with foregut tumors. Nutr Cancer. 2012;64(8):1174-81.. APM has been used to indirectly determine the nutritional status1414. Lameu EB, Poziomyck AK, Moreira LF, Consequences of malnutrition in the surgical patient. In: Campos ACL, editor. The Treaty of Nutrition and Metabolism in Surgery. Rio de Janeiro: Rubio; 2013. p. 55-64.,2020. Lameu EB, Gerude MF, Corrêa RC, Lima KA. Adductor policis muscle: a new anthropometric parameter. Rev Hosp Clin. 2004;59(2):57-62.,2323. Schlüssel MM, Anjos LA, Kac G. A dinamometria manual e seu uso na avaliação nutricional. Rev Nutr. 2008;21(2):223-35., being considered as one of the best single predictors of mortality in a recent study with patients undergoing resection of upper GIT tumor88. Poziomyck AK, Weston AC, Lameu EB, Cassol OS, Coelho LJ, Moreira LF. Preoperative nutritional assessment and prognosis in patients with foregut tumors. Nutr Cancer. 2012;64(8):1174-81..
The bioimpedance analysis (BIA) uses the measured phase angle, which is the result of the electric current stored in cell membranes. However, more accurate results depend on regression equations and lower values indicate reduction in cell integrity or cellular death2424. Barbosa-Silva MC, Barros AJ. Bioelectrical impedance analysis in clinical practice: a new perspective on its use beyond body composition equations. Curr Opin Clin Nutr Metab Care. 2005;8(3):311-7..
Some authors also use weight loss as a nutritional screening marker. In a study of patients with esophageal cancer, Van der Schaaf et al. found that preoperative loss weight exceeding 10% was associated with a reduction of the overall five-year survival after resection, but not with increased risk of postoperative complications2525. van der Schaaf MK, Tilanus HW, van Lanschot JJ, Johar AM, Lagergren P, Lagergren J, et al. The influence of preoperative weight loss on the postoperative course after esophageal cancer resection. J Thorac Cardiovasc Surg. 2013;20(13):490-5..
Laboratory Methods
Albumin and other proteins used as nutritional markers can be affected by many factors and clinical conditions such as inflammation, malnutrition, diabetes, liver disease or surgical trauma. But they also have been used to assess overall nutritional status, severity, progression and prognosis of the disease2626. Gupta D, Lis CG. Pretreatment serum albumin as a predictor of cancer survival: a systematic review of the epidemiological literature. Nutr J. 2010;9:69., assuming that plasma levels indeed reflect the rate of synthesis27-29. However, other factors such as liver function, inflammation markers and endocrine stress result in increased levels of cortisol, which also affects albumin regulation2727. Hülshoff A, Schricker T, Elgendy H, Hatzakorzian R, Lattermann R. Albumin synthesis in surgical patients. Nutrition. 2013;29(5):703-7..
Serum albumin has also been described as an independent survival prognostic factor in many tumors, displaying an inverse relation to complications and length of postoperative hospitalization or intensive care, mortality, and resumption of oral intake2626. Gupta D, Lis CG. Pretreatment serum albumin as a predictor of cancer survival: a systematic review of the epidemiological literature. Nutr J. 2010;9:69.,2727. Hülshoff A, Schricker T, Elgendy H, Hatzakorzian R, Lattermann R. Albumin synthesis in surgical patients. Nutrition. 2013;29(5):703-7.. Decreased serum albumin also proved to be an independent prognostic factor for cancer patients with unknown primary site2626. Gupta D, Lis CG. Pretreatment serum albumin as a predictor of cancer survival: a systematic review of the epidemiological literature. Nutr J. 2010;9:69., but further clinical trials are needed to better define the baseline risks in patients with cancer26-29.
Recently, a significant association between increased C-reactive protein (CRP) and poor clinical outcome has been demonstrated in patients with pancreatic cancer3030. Szkandera J, Stotz M, Absenger G, Stojakovic T, Samonigg H, Kornprat P, et al. Validation of C-reactive protein levels as a prognostic indicator for survival in a large cohort of pancreatic cancer patients. Br J Cancer. 2013;110(1):183-8.. CRP has also been shown to be an independent prognostic indicator in colorectal carcinoma3131. Takasu C, Shimada M, Kurita N, Iwata T, Nishioka M, Morimoto S, et al. Impact of C-reactive protein on prognosis of patients with colorectal carcinoma. Hepatogastroenterology. 2013;60(123):507-11..
Score Methods
A number of studies have consistently shown that no method or tool alone is enough to predict nutritional status33. Ryu SW, Kim IH. Comparison of different nutritional assessment in detecting malnutrition among gastric cancer patients. World J Gastroenterol. 2010;16(26):3310-7.. The mini nutritional assessment (MNA) classified as normal, borderline or malnutrition in the elderly involves anthropometric measurements, overall evaluation, dietary questionnaire and subjective evaluation3232. Guigoz Y, Vellas B, Garry PJ. Assessing the nutritional status of the elderly: The Mini Nutritional Assessment as part of the geriatric evaluation. Nutr Rev. 1996;54(1 Pt 2):S59-65.. A cross-sectional study with elderly patients (n = 109) observed that combined arm circumference (AC) and BMI allowed to predict the MNA classification3333. Leandro-Merhi VA, Aquino JLB, Camargo JGT, Frenhani PB, Bernardi JLD, McLellan KCP. Clinical and nutritional status of surgical patients with and without malignant diseases: cross-sectional study. Arq Gastroenterol. 2011;48(1):58-61.. In another study evaluating elderly patients with hepatocellular carcinoma, the results suggested that MNA was adequate to identify the risk of deterioration in the quality of life and functional status, and to determine the risk of malnutrition2323. Schlüssel MM, Anjos LA, Kac G. A dinamometria manual e seu uso na avaliação nutricional. Rev Nutr. 2008;21(2):223-35..
The Nutritional Risk Index (NRI) is calculated by the equation of serum albumin and weight ratio33. Ryu SW, Kim IH. Comparison of different nutritional assessment in detecting malnutrition among gastric cancer patients. World J Gastroenterol. 2010;16(26):3310-7.,3434. Hsu WC, Tsai AC, Chan SC, Wang PM, Chung NN. Mini-nutritional assessment predicts functional status and quality of life of patients with hepatocellular carcinoma in Taiwan. Nutr Cancer. 2012;64(4):543-9.; the levels of serum protein and albumin significantly correlated with malnutrition, but not with subgroups of SGA or Nutritional Risk Screening 2002 (NRS-2002)3434. Hsu WC, Tsai AC, Chan SC, Wang PM, Chung NN. Mini-nutritional assessment predicts functional status and quality of life of patients with hepatocellular carcinoma in Taiwan. Nutr Cancer. 2012;64(4):543-9..
The Glasgow Prognostic Score (GPS) has been used to determine long-term outcome (survival) in cases of curable gastric cancer3434. Hsu WC, Tsai AC, Chan SC, Wang PM, Chung NN. Mini-nutritional assessment predicts functional status and quality of life of patients with hepatocellular carcinoma in Taiwan. Nutr Cancer. 2012;64(4):543-9., according to the degree of inflammation inferred by the CRP and albumin levels,with scores ranging from from 0 to 23535. Kubota T, Hiki N, Nunobe S, Kumagai K, Aikou S, Watanabe R, et al, Significance of the inflammation-based Glasgow prognostic score for short- and long-term outcomes after curative resection of gastric cancer. J Gastrointest Surg. 2012;16(11):2037-44.. It may be useful in determining the nutritional status, since inflammation is a relevant factor in the development of cachexia, though not yet evaluated in the short term3434. Hsu WC, Tsai AC, Chan SC, Wang PM, Chung NN. Mini-nutritional assessment predicts functional status and quality of life of patients with hepatocellular carcinoma in Taiwan. Nutr Cancer. 2012;64(4):543-9..
In a study with 74 patients, 54 (72%) with GIT tumors, the Nutrition Inflammatory Index (NII) was an alternative method for biochemical nutritional assessment and monitoring of patients with cancer and systemic inflammation3636. McMillan DC. Systemic inflammation, nutritional status and survival in patients with cancer. Curr Opin Clin Nutr Metab Care. 2009;12(3):223-6.,3737. Alberici PC, Paiva OS, González MC. Association between an inflammatory-nutritional index and nutritional status in cancer patients. Nutr Hosp. 2013;28(1):188-93..
The NRS-2002 is a nutritional and disease severity score, being the preferred method for evaluating patients at risk or malnourished and for selecting those that could benefit from nutritional support33. Ryu SW, Kim IH. Comparison of different nutritional assessment in detecting malnutrition among gastric cancer patients. World J Gastroenterol. 2010;16(26):3310-7.. This nutritional screening was directly related to tumor stage in 100 newly diagnosed patients with stomach cancer, and inversely correlated with quality of life, making it a useful tool to identify patients in need of nutritional support throughout treatment3838. Gavazzi C, Colatruglio S, Sironi A, Mazzaferro V, Miceli R. Importance of early nutritional screening in patients with gastric cancer. Br J Nutr. 2011;106(12):1773-8..
In 2011, Argiles et al. presented a new tool called "The Cachexia Score" (CASCO), which considers weight and loss of lean body mass, anorexia, inflammatory, immunologic and metabolic disorders, physical performance and quality of life. The score (up to 100) appears to be adequate, although further prospective studies are needed to better define its sensitivity and specificity in different types of cancers, including GIT tumors3939. Argilés JM, López-Soriano FJ, Toledo M, Betancourt A, Serpe R, Busquets S. The cachexia score (CASCO): a new tool for staging cachectic cancer patients. J Cachexia Sarcopenia Muscle. 2011;2(2):87-93..
FINAL CONSIDERATIONS
Various methods have allowed measurements of body composition, protein and lipid reserves by traditional anthropometry with the use of more sophisticated equipment. Currently, the most accurate techniques for assessment of nutritional status are more expensive, less available and inappropriate for repetitive measures22. Van Cutsem E, Arends J. The causes and consequences of cancer-associated malnutrition. Eur J Oncol Nur. 2005;9 Suppl 2:S51-63..
Many studies have also revealed the inadequacy of any tool or method used alone in safely predicting the nutritional status of patients with cancer, which clearly demonstrates the lack of a specific measure as the gold standard33. Ryu SW, Kim IH. Comparison of different nutritional assessment in detecting malnutrition among gastric cancer patients. World J Gastroenterol. 2010;16(26):3310-7.,88. Poziomyck AK, Weston AC, Lameu EB, Cassol OS, Coelho LJ, Moreira LF. Preoperative nutritional assessment and prognosis in patients with foregut tumors. Nutr Cancer. 2012;64(8):1174-81., although the real need for a specific pattern is questionable. Still, this led to the attempt to combine evaluation measures, such as anthropometric and laboratory data, in order to increase sensitivity and specificity3030. Szkandera J, Stotz M, Absenger G, Stojakovic T, Samonigg H, Kornprat P, et al. Validation of C-reactive protein levels as a prognostic indicator for survival in a large cohort of pancreatic cancer patients. Br J Cancer. 2013;110(1):183-8., and thus to more adequately evaluate oncology and surgical patients. Overall, the assessment instruments routinely used do not consider the risk and complications of ongoing cancer treatment, such as chemotherapy and radiation, their side effects in the gastrointestinal tract or post-operative implications of the inflammatory response in cancer patients in general.
This is even more relevant when considering patients with GIT tumors, for whom there is no consensus on the best tool or method to assess nutritional status, especially those with upper GIT tumors, most severely affected by nutritional and immune deficiency, and by the effect of major surgical procedures and complications in the immediate postoperative period when compared with lower GIT tumors cases. Probably the course of nutritional depletion between the two tumor locations is very different, as are quite distinct the nutritional support requirements. Thus, attempts to develop new protocols, trials, scores or new combinations of more specific approaches are necessary to better assess the nutritional status in patients with GIT tumors, especially considering those patients with upper GIT tumors, who are more malnourished, more immunocompromised and at increased risk of morbidity and mortality, as recently demonstrated in our series88. Poziomyck AK, Weston AC, Lameu EB, Cassol OS, Coelho LJ, Moreira LF. Preoperative nutritional assessment and prognosis in patients with foregut tumors. Nutr Cancer. 2012;64(8):1174-81.. To date, as far as we know, there is insufficient data to establish a consensus for this group of patients. Therefore, it would be interesting to simulate, add or combine features already validated with objective variables to test a single questionnaire specifically designed to better predict postoperative morbidity and mortality in patients with gastrointestinal cancer.
In summary, the GPS score, the PG-SGA and some anthropometric parameters are considered suitable for chronic and cancer patients in general. However, a better combination of laboratory, anthropometric and subjective evaluations is required, considering an instrument more focused in GIT cancer patients, since malnutrition in these patients is much more severe compared with the one in patients with tumors in other locations.
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Fonte de financiamento: nenhuma.
Publication Dates
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Publication in this collection
May-Jun 2016
History
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Received
28 Jan 2016 -
Accepted
12 Apr 2016