Nutritional status, symptoms, and inflammation among older adults with different functional levels with cancer in palliative care

Abstract

Objectives  This study aimed to assess the nutritional status, symptoms, food intake, and inflammatory activity of older adults with cancer with the Karnofsky Performance Status scale (KPS) ≥50% receiving palliative care.

Methods  Cross-sectional study with outpatients divided into two groups by the Karnofsky Performance Status scale: 80 to 100% (Group 1) and 50 to 70% (Group 2). Nutritional status was assessed using the Mini Nutritional Assessment (MAN), food intake using the 24-hour food recall, symptoms using the Edmonton Symptom Assessment System and serum interleukin-6 (IL-6) levels were measured.

Results  Age was 69.6±5.9 years. MNA was higher for Group 1 (23.4±2.7 vs 19.4±3.1, p<0.001). Group 2 ingested lower amounts of total energy (p=0.003), carbohydrates (p=0.017), protein (p=0.007), total fat (p=0.004), saturated fat (p=0.006), fiber (p=0.012), and dietary cholesterol (p=0.009). Group 2 had a greater intensity of symptoms such as pain (p=0.02), nausea (p=0.01), shortness of breath (p=0.04) and lack of sensation of wellbeing. There was no difference in IL-6 between groups (p=0.13); however, higher IL-6 was associated with a higher prevalence of dyspnea and a lower calorie, carbohydrate, and dietary cholesterol intake.

Conclusions  The lower the functional capacity of older cancer patients under palliative care, the worse their nutritional status, with lower intake of nutrients and increased number of symptoms. This study brings an important scientific contribution to older adults with cancer in palliative care, supporting nutritional and symptom assessment in health care.

Keywords
Elderly Nutrition; Cancer; Palliative Care; Functioning.

Resumo

Objetivos  Este estudo teve como objetivo avaliar o estado nutricional, sintomas, ingestão alimentar e atividade inflamatória de pessoas idosas com câncer com escala de Karnofsky Performance Status (KPS) ≥50% em cuidados paliativos.

Métodos  Estudo transversal com pacientes ambulatoriais divididos em dois grupos pela escala Karnofsky Performance Status 80 a 100% (Grupo 1) e 50 a 70% (Grupo 2). Foi avaliado o estado nutricional pela Mini Avaliação Nutricional (MAN), a ingestão alimentar pelo recordatório alimentar de 24 horas, sintomas pelo Edmonton Symptom Assessment System e dosada a interleucina-6 sérica (IL-6).

Resultados  A idade foi de 69,6±5,9 anos. A MAN foi maior no Grupo 1 (23,4±2,7 vs 19,4±3,1, p<0,001). O grupo 2 ingeriu menores quantidades de energia total (p=0,003), carboidratos (p=0,017), proteína (p=0,007), gordura total (p=0,004), gordura saturada (p=0,006), fibras (p=0,012) e colesterol dietético (p=0,009). O grupo 2 apresentou maior intensidade de sintomas como dor (p=0,02), náusea (p=0,01), falta de ar (p=0,04) e falta de sensação de bem-estar. Não houve diferença na IL-6 entre os grupos (p=0,13), entretanto, maior IL-6 foi associado a maior prevalência de dispneia e menor ingestão de calorias, carboidratos e colesterol dietético.

Conclusões  Quanto menor a capacidade funcional das pessoas idosas com câncer em cuidados paliativos, pior o estado nutricional, com menor ingestão de nutrientes e maior número de sintomas. Este estudo traz importante contribuição científica para pessoas idosas com câncer em cuidados paliativos, apoiando a avaliação nutricional e de sintomas no cuidado à saúde.

Palavras-chave
Nutrição da Pessoa Idosa; Câncer; Cuidados Paliativos; Funcionalidade.

INTRODUCTION

Cancer is one of the leading causes of death worldwide, with an estimated 9.7 million deaths in 2022, the majority of which occurred in developing countries¹. Cancer is associated with aging, with age being the greatest risk factor for many types of cancer and for increased mortality². The incidence of cancer in older adults worldwide was 12.9 million in 2022, which corresponds to approximately 66% of all cases in the general population³.

According to data from the National Cancer Institute (2022), the estimate for the period from 2023 to 2025 indicates that there will be 704 thousand new cases of cancer in Brazil, being around 57% in older adults³,⁴. Despite the great advances in medicine, cure rates are still low. However, because of these advances in medicine, patients considered to have no curative therapeutic possibilities may live for years with the disease and require control of pain and of the other symptoms, including psychological, social, and spiritual aspects, so that they may obtain a better quality of life regardless of their prognosis. Currently, in the world, it is estimated that only one in every patient who needs palliative care is receiving it, which is worse in emerging countries⁵.

Cancer patients have a situation of imbalance between pro- and anti-inflammatory cytokines that results in increased concentrations of tumor necrosis factor-alpha (TNF-α) and interleukins (IL) such as IL-1 and IL-6. Inflammation is one of the factors that harm the nutritional status of cancer patients, with reduced appetite and/or increased metabolism⁶.

The nutritional status of cancer patients is significantly compromised, with a negative effect on their quality of life and survival⁷. Approximately 80% of the patients who receive a diagnosis of cancer already show protein-calorie malnutrition at the time of diagnosis. Malnutrition is due to the imbalance between food intake and the nutritional requirements of these patients, with a compromised nutritional status. This, in turn, is associated with increased morbidities and the favoring of cachexia, a frequent complication among patients with malignant neoplasms⁸. It has been estimated that about 20% of cancer patients die due to malnutrition and its consequences rather than due to the malignancy of the disease itself⁹.

Like malnutrition, cancer-associated inflammation is involved in the incidence and maintenance of other symptoms, such as pain, fatigue, sleep disorders, and mood changes¹⁰. In the presence of intense and prolonged different symptoms, patients may reach a wearing down situation denoted symptom burden. With the progression of the disease, patients experience increasing functional loss and dependence for daily life activities.

Thus, it is necessary to establish a relationship between the nutritional status of the patient and his symptoms, considering different levels of functionality to obtain a better control of symptoms by means of appropriate nutritional therapy. The objective of the present study was to assess the nutritional status, food consumption, symptoms, and inflammation of older patients with cancer with different levels of functionality receiving palliative care.

METHOD

This was a cross-sectional study conducted in the Services of Oncology and Palliative Care of the University Hospital of Ribeirão Preto Medical School, University of São Paulo (HCFMRP-USP) on a convenience (non-probabilistic) sample. No sample calculation was performed due to the evaluation of different parameters that were little studied together (nutritional status, symptoms, and inflammation). After collecting the data, we calculated the power of the sample using the most important variable of the study, the Mini Nutritional Assessment, finding that the power of the test was 97.67, with a beta or type II error of 2.33%. The study was approved by the Research Ethics Committee of the HCFMRP-USP (approval number: 2.549.457) and all subjects or persons responsible gave written informed consent to participate.

The inclusion criteria were older patients aged 60 years or more with an immuno-histochemical diagnosis of cancer and receiving palliative care on an ambulatory basis, with a KPS of 50% or more. The exclusion criteria were a diagnosis of cancer of the gastrointestinal tract and treatment with chemotherapy or radiotherapy during the last 15 days, in order to prevent interference with the digestive symptoms reported.

After reviewing the medical records, which allowed selecting the older adults who could participate, contact was made by telephone, when 85 outpatients agreed to participate. However, only 35 volunteers came to the hospital and signed the informed consent term. The other 50 withdrew from participation due to transportation difficulties, lack of companionship, or physical indisposition (Figure 1). Of these 35 volunteers, 20 had good functionality and a Karnofsky Palliative Scale (KPS) score of 80 to 100% (Group 1) and 15 had compromised functionality and a KPS score of 50 to 70% (Group 2).

Figure 1
Flowchart of selection of older volunteers with cancer in palliative care. KPS: Karnofsky Performance Status. Ribeirão Preto, SP, 2020.

The nutritional status of the volunteers was evaluated with the Mini Nutritional Assessment (MNA) instrument and their food consumption was assessed with the 24-hour dietary recall (24hDR). The calorie and macronutrient supply were calculated using a specific software, (Professional Nutrition DietPro 5.1l) updated with data of the Brazilian Food Composition Table (TACO).

Anthropometric evaluation was performed on the basis of the following variables: weight (Welmy® electronic scale, model W 110 H), height (Alturexata® stadiometer); and body mass index (BMI), and the criteria for classification were the cutoff points proposed by the Nutrition Screening Initiative, published by Lipschitz¹¹ and recommended by the Health Ministry for older adults, namely, arm circumference (AC) and calf circumference (CC), both measured according to the techniques described by the WHO (1995)¹². Based on the AC measurements, the percent adequacy of these variables was calculated according to sex and age using the 50th percentile values of AC, and the values recommended by Blackburn and Thornton¹³ were used for the classification of nutritional status. CC values were used to classify the subjects as being malnourished or not (< 31 cm) or not (≥31 cm)¹².

The functionality of the volunteers was determined using the Karnofsky Performance Status scale (KPS), a scale developed in order to assess the physical capacity of cancer patients, in which lower values ​​are related to a worse prognosis¹⁴. The presence and grading of symptoms were analyzed using the Edmonton Symptom Assessment System (ESAS) scale in the Portuguese version¹⁵.The symptoms assessed and the intensity reported from 0 (zero) (no symptoms) to 10 (worst possible intensity) were pain, tiredness, nauseas, depression, anxiety, somnolence, lack of appetite, shortness of breath, lack of sensation of wellbeing.

Serum interleukin-6 (IL-6) level was determined by ELISA using high-sensitivity kits from R&D Systems (Minneapolis, MN, USA) according to manufacturer instructions.

This inflammatory marker was chosen because it is the most studied in cancer.

In statistical analysis, data were first submitted to descriptive analysis and the Levene test was used to determine the homogeneity of variance of the data. Chi-square test was used with categorical variables, and data showing parametric distribution were analyzed by the unpaired Student’s “t” test. Data showing nonparametric distribution were analyzed by the Mann-Whitney and Wilcoxon tests. Correlations were determined using the Spearman test. The level of significance was set at <0.05.

DATA AVAILABILITY

The entire dataset supporting the findings of this study has been made available at: https://figshare.com/articles/dataset/Nutritional_status_symptoms_and_inflammation_among_older_adults_with_different_functional_levels_with_cancer_in_palliative_care_/28582964?file=52947185. doi: 10.29327/7510318.

RESULTS

The study was conducted on 35 older cancer patients receiving palliative care, 20 of them (57.1) with a KPS value of 80 to 100 (Group 1) and 15 (42.9%) with a KPS value of 50 to 70 (Group 2), with no difference in age, sex, and primary cancer site between groups (Table 1).

Table 1
General characteristics of older individuals with cancer in palliative care. Ribeirão Preto, SP, 2020.

	Group 1 N=20	Group 2 N=15
Sex (Men)	18 (90%)	13 (87%)	p>0.05*
Age (Years)	69.8±4.8	69.3±7.3	p> 0.05#
Primary Cancer Site			p>0.05
Lung	8 (40%)	5 (33.3%)
Prostate	4 (20%)	4 (26.7%)
Urinary	2 (10%)	1 (6.7%)
Penis/Testicle	1 (5%)	1 (6.7%)
Breast	2 (10%)	1 (6.7%)
Others	2 (10%)	1 (6.7%)

• *Chi-square; #Unpaired Student´s test

BMI values revealed the greater occurrence of overweight in Group 1 and low weight in Group 2 (Table 2).

Table 2
Anthropometric assessment and nutritional status of older individuals with cancer in palliative care. Ribeirão Preto, SP, 2020.

	Group 1 N=20	Group 2 N=15
BMI (Kg/m2)	27.8±4.3	23.1±3.3	p=0.001#
Low Weight	1 (5%)	7 (46.7%)	p=0.001*
Eutrophy	9 (45%)	6 (40%)
Overweight	10 (50%)	2 (13.3%)
AC (cm)	30.3±3.3	24.2±3.3	p<0.001#
CC (cm)	38.1±4.6	32.9 ±2.6	P<0.001#
MNA	23.4±2.7	19.4 ±3.1	p<0.001#
Normal	10 (50%)	0	P<0.001*
At risk	10 (50%)	10 (66.7%)
Malnutrition		5 (33.3%)

• BMI: body mass index; AC: arm circumference; CC: calf circumference; MNA: Mini Nutrition Assessment; *Chi-square; #Unpaired Student’s test

Mean AC values differed between groups (Table 2), revealing a malnutrition index of 80% for Group 2 and of only 5% for Group 1. CC values showed that 33.3% of Group 2 patients had malnutrition, as opposed to only 5% of Group 1 patients, with a significant difference between mean values (Table 2).

In the assessment of nutritional status, the MNA data revealed that Group 2 had a higher prevalence of malnutrition (33.3%) and risk of malnutrition (66.7%). There was a difference in the mean MNA score between the groups (Table 2).

Group 2 showed lower ingestion of total energy, carbohydrates, protein, total fat, saturated fat, fibers and cholesterol, compared to Group 1, with no difference being observed only regarding the intake of polyunsaturated fat (Table 3).

Table 3
Food intake and percentage of total energy in Group 1 (80 -100% KPS) and Group 2 (50 -70% KPS) of older individuals with cancer in palliative care. Ribeirão Preto, SP, 2020.

Variables	Median		Minimum		Maximum		p* value
	G1	G2	G1	G2	G1	G2
Energy (Kcal)	1814.4	966.2	966.1	612.6	4202.3	2520.7	0.003
20 to 35 kcal/kg/day
Carbohydrate (g)	237.5	152.4	70.4	70.4	324.1	347.7	0.017
%TEV - DRI: 45-65%	49%	54.9%
Protein (g)	75.5	47.4	39.6	5.9	288.5	153.3	0.007
%TEV- DRI: 10-35%	19.5%	17.6%
Total fat (g)	56.7	40.6	35.7	5.9	71.8	82.4	0.004
%TEV – DRI: 20-35%	30%	28.1%
Saturated fat (g)	18.8	11.6	7.35	3.8	50	26.9	0.006
%TEV – DRI: <10%	9.6%	8.9%
Polyunsaturated fat (g)	8.8	10.9	3.9	1.3	18.6	18.5	0.78
%TEV – 6-10%	5.2%	8%
Fiber (g)	20.2	7.3	4.5	3.6	61.21	60.8	0.012
DRI: 21-30 g/day
Dietary cholesterol (mg)	173.7	92.3	92.2	25.6	860	748.4	0.009
DRI: <300 mg/day (100%)	58%	30.8%

• G1 = Group 1; G2 = Group 2; kcal = kilocalories; g = gram; mg = milligram; TEV = Total Energy Value; DRI = Dietary Reference Intake; KPS = Karnofsky Performance Status Scale. * Mann-Whitney test for independent samples

According to the composition of the diet, the intake of carbohydrate, protein, total fat, and saturated fat was within recommended values, except for polyunsaturated fat, which was below recommended values in Group 1, and fiber that was below in both groups (Table 3).

However, in Group 2, the mean calorie and protein intake divided by the mean weight of the group revealed that intake was lower than recommended, with a calorie intake of 19.2 kcal/kg/day and a protein intake of 0.8 g/kg/day. Group 1 showed borderline recommended values, with a calorie intake of 23.2 kcal/kg/day and a protein intake of 1.1 g/kg/day.

The symptoms assessed by ESAS that showed a difference in median score between Group 1 and Group 2 were pain (0 vs. 5, p=0.001), nausea (0 vs. 1, p=0.003), somnolence (0 vs. 3, p=0.028), lack of appetite (1 vs. 4, p=0.017), shortness of breath (0 vs. 1, p=0.046), and lack of a feeling of wellbeing (0.5 vs. 4, p< 0.001), whereas tiredness, depression and anxiety did not differ between groups (p=0.080. p=0.59 and p=0.14, respectively). The intensity of the symptoms assessed, such as pain, nausea, shortness of breath and lack of a feeling of wellbeing was higher in Group 2 (Table 4).

Table 4
Intensity of symptoms determined by ESAS in Group 1 (80 -100% KPS) and Group 2 (50 -70% KPS) of older individuals with cancer in palliative care. Ribeirão Preto, SP, 2020.

	Group	No symptom	Mild	Moderate	Intense	p* value
Pain	G1	11 (55%)	6 (30%)	2 (10%)	1 (5%)	0.02
	G2	1 (6.7%)	4 (26.7%)	9 (60%)	1 (6.7%)
Tiredness	G1	11 (55%)	5 (25%)	3 (15%)	1 (5%)	0.37
	G2	3 (20%)	7 (46.7%)	3 (20%)	2 (13.3%)
Nausea	G1	19 (90%)	1 (5%)	1 (5%)	0 (0%)	0.01
	G2	5 (33.3%)	7 (46.7%)	3 (20%)	0 (0%)
Depression	G1	11 (55%)	7 (35%)	1 (5%)	1 (5%)	0.48
	G2	7 (46.7%)	5 (33.3%)	2 (13.3%)	1 (6.7%)
Anxiety	G1	8 (40%)	6 (30%)	5 (25%)	1 (5%)	0.48
	G2	5 (33.3%)	1 (6.7%)	6 (40%)	3 (20%)
Somnolence	G1	15 (75%)	1 (5%)	3 (15%)	1 (5%)	0.12
	G2	5 (33.3%)	3 (20%)	5 (33.3%)	2 (13.3%)
Lack of appetite	G1	9 (45%)	7 (35%)	4 (20%)	0 (0%)	0.07
	G2	2 (13.3%)	5 (33.3%)	5 (33.3%)	3 (20%)
Shortness of breath	G1	20 (100%)	0 (0%)	0 (0%)	0 (0%)	0.04
	G2	9 (60%)	4 (26.7%)	1 (6.7%)	1 (6.7%)
Lack of sensation of	G1	10 (50%)	8 (40%)	1 (5%)	1 (5%)	0.007
wellbeing	G2	1 (6.7%)	3 (20%)	10 (66.7%)	1 (6.7%)

• G1=Group 1; G2=Group 2; ESAS= Edmonton Symptom Assessment System; KPS= Karnofsky Performance Status Scale. * Chi-square test.

The symptom most frequently detected in Group 1 was anxiety, reported by 60% of the volunteers, whereas the symptoms of pain and lack of a feeling of wellbeing were reported by 93.3% of Group 2 subjects.

There was no significant difference in IL-6 levels between groups (p=0.13), although Group 2 showed higher values, with a median of 34.2 pg/mL compared to 26.2 pg/mL for Group 1. The maximum IL-6 concentrations were 378.84 pg/mL for Group 1 and 524.6 pg/mL for Group 2 It was observed that a higher plasma IL-6 concentration was associated with more complaints of dyspnea (r=0.342, p=0.045), lower total calorie (r=-0.437, p=0.009), carbohydrate (r=-0.387, p=0.021), and dietary cholesterol intake (r=-0.489, p=0.003).

DISCUSSION

In the present study, the application of the MNA revealed that 50% of Group 1 patients were at risk of malnutrition, while 66.7% of Group 2 patients were at risk of malnutrition and 33.3% were already malnourished. Pelissaro et al.¹⁶ observed higher percentages, with 46.7% of their patients being classified as malnourished and 44.8% as being at risk of malnutrition. Another study has reported similar proportions of malnutrition among cancer patients receiving palliative care, although its sample was more heterogeneous regarding the methodology of nutritional assessment¹⁷. In the present study, assessment of nutritional status based on the BMI revealed that 50% of Group 1 patients were overweight, 45% were of normal weight, and 5% were of low weight, while 46.7% of Group 2 patients were of low weight, 40% were of normal weight and 13.3% were overweight, with a higher prevalence of malnutrition being detected based on the MNA than based on the BMI. Similar results were detected in other studies which observed a higher percentage of nutritional risk and malnutrition when using the MNA rather than the BMI¹⁸. The nutritional assessment of older cancer patients based on the BMI has limitations due to the changes in body composition (reduction of lean mass and height, dehydration and higher percentage of body fat) and clinical complications that may impair the measurement of these parameters. We observed high indices of malnutrition, and a risk of malnutrition based on the MNA, a result explained by the fact that this is a method that comprises anthropometry, dietary assessment, global clinical evaluation, self-perception of health and risk of malnutrition, favoring an early diagnosis of nutritional risk.

Considering CC, only 17.1% of the patients were classified as malnourished, 5% of them in Group 1 and 33.3% in Group 2. Thus, most patients showed values that did not indicate a marked loss of muscle mass. These findings agree with those reported by Oliveira et al.¹⁹ in a study assessing 68 cancer patients, showing a high percentage of individuals without malnutrition as determined by the BMI (67.6%) and by the CC (92.2%). However, based on the AC, 80% of Group 2 patients showed some degree of malnutrition. The CC and AC parameters, mainly associated, can contribute to the clinical detection of sarcopenia, since they improve the sensitivity of the SARC-F instrument. (Strength, Assistance in walking, Rise from a chair, Climb stairs, and Falls)²¹.

The ideal instrument for assessing malnutrition in patients with advanced cancer has not yet been found²¹.

Regarding the percentage in the diet recommended, in Group 1 the values for polyunsaturated fat and fiber were below the recommended levels, while this happened only for fiber in Group 2. However, the calorie and protein intake of Group 2 was below the level recommended by the National Cancer Institute, whose energy recommendation is 20 to 35 kcal/kg/day and a protein intake ranging from 1 to 2 g/kg body weight/day, depending on stress and clinical complications. The intake of protein was borderline close to the recommended levels in Group ^{1 22}. Surwillo and Wawrzyniak²³ reported that, regarding mean calorie consumption, the intake of carbohydrates and proteins was insufficient in patients with breast cancer.

Older patients with advanced stage cancer have different symptoms that may directly interfere with their functional capacity, possibly leading to a worse nutritional status. In the present study, lack of appetite was one of the symptoms most frequently reported by the patients, with a prevalence of 55% in Group 1 and of 86.7% in Group 2 and with the symptom being more intense in 20% of Group 2 patients. In the study by Duval et al., they found a lack of appetite in 100% of the patients²⁴. Probably, the symptom of anorexia, which is so prevalent, was involved in the lower caloric and protein intake of individuals with lower functionality.

Another highly prevalent symptom is pain, which affects most cancer patients in different stages of the disease. In the present study, pain was the symptom most frequently reported by Group 2, together with a reduction of wellbeing (93.3%), and was the fourth highest symptom in Group 1 (45%), with a difference in both intensity and median values between both groups. Faller et al.²⁵ observed that pain was the symptom most frequently reported by geriatric cancer patients, with a frequency of 90.1%, a value similar to that detected in Group 2. Among the patients reporting pain in both groups, 78.2% reported some degree of depression. In Group 2, this index reached 85.7%. Thus, there may be a relationship between pain and depression among cancer patients receiving palliative care, with the prevalence of depression being 45% in Group 1 and 53.3% in Group 2 of the present sample.

Tiredness was highly prevalent in Group 2, with an 80% index, being reported together with other symptoms such as pain and lack of sleep, among others. This can be considered one of the worst symptoms reported by cancer patients owing to its high prevalence and to the fact that it causes limitations of the daily activities of the patients.

In the present study, there was no significant difference in IL-6 concentrations between groups 1 and 2, even though group 2 showed higher values. The small sample size may not have been sufficient to permit the detection of a statistically significant difference. However, there was a correlation between IL-6 concentration and some of the parameters analyzed such as dyspnea. This symptom was more present with higher IL-6 concentrations and, the higher the IL-6 levels, the lower the values of calorie, carbohydrate, and dietary cholesterol intake.

Inflammatory markers such as IL-6 were significantly associated with malnutrition, demonstrating that, the greater the inflammatory response, the worse the nutritional status and the weight loss of the patients. Many studies conducted on patients with advanced cancer on palliative care have observed a significant association between inflammation and undernutrition, with higher serum levels of inflammatory substance among patients with greater deficits of nutritional status²⁶,²⁷. Pro-inflammatory cytokines may contribute to symptoms such as pain and worse quality of life among cancer patients.

The KPS scale that was used to assess functionality and divide the studied groups proved to be quite useful in discriminating them regarding nutritional status, food intake and symptoms, and a KPS value below 80 can be used as a warning for a more detailed nutritional assessment in older patients with cancer in palliative care. Preventive actions could be implemented when the KPS is higher. The ESAS should be applied to all individuals, since in the group with better functionality there was already a high prevalence of symptoms that can contribute to clinical, functional, and nutritional worsening.

The multidisciplinary palliative care team approach is indicated for all patients with advanced cancer and for those who, even in the early stages of the disease, with the possibility of cure and good functionality, present uncontrolled symptoms or compromised quality of life²⁸.

CONCLUSIONS

The present study allowed us to determine that, the lower the functional capacity of older cancer patients under palliative care, the worse their nutritional status, with lower intake of nutrients such as total calories, carbohydrates, protein, total fat, saturated fat, fiber and dietary cholesterol.

As there is a concomitant greater number and intensity of symptoms with reduced functionality, it is essential to carry out adequate management of symptoms to obtain nutritional improvement.

The higher the degree of inflammation, the stronger the complaint of dyspnea and the lower the consumption of calories and carbohydrates. On this basis, we may question whether older cancer patients obtain the proper palliative care as the disease progresses and their functional capacity is reduced. Medical and nutritional intervention have to be applied as early as possible, to get a significant improvement of nutritional status and symptoms.

ACKNOWLEDGMENTS

We would like to thank Lívia Maria Cordeiro Simões Ambrosio for helping in the biochemical analysis. We would like to thank all the participants and their families.

• Funding
  Fundação de Apoio ao Ensino, Pesquisa e Assistência do Hospital das Clínicas da FMRP - USP (FAEPA), Process number: 1690. Master's scholarship: CAPES, No 1755397.

References

• ¹ World Health Organization: Cancer. Disponível em: https://www.who.int/news/item/01-02-2024-global-cancer-burden-gro; [acesso em 11 out 2024].
  » https://www.who.int/news/item/01-02-2024-global-cancer-burden-gro
• ² Havas A,Yin S, Adams PD. The role of aging in cancer. Mol Oncol 2022;16(18):3213-3219. doi: 10.1002/1878-0261.13302.
• ³ International Agency for Research on Cancer. Cancer Today/IARC – Disponível em: https://gco.iarc.who.int. Data version: Globocan 2022 (version 1.1); [acesso em 08 fev 2024]. All Rights Reserved 2025.
  » https://gco.iarc.who.int
• ⁴ Instituto Nacional de Câncer (INCA). 2023 estimate: incidence of cancer in Brazil [Estimativa 2023: incidência de câncer no Brasil]. Rio de Janeiro: INCA; 2022.
• ⁵ Organização Pan-Americana de Saúde. Disponível em: https://www.paho.org/en/topics/palliative-care; [acesso em 03 fev 2025].
  » https://www.paho.org/en/topics/palliative-care
• ⁶ Dolan RD, Laird BJA, Klepstad P, Kaasa S, Horgan PG, Paulsen Ø, et al. An exploratory study examining the relationship between performance status and systemic inflammation frameworks and cytokine profiles in patients with advanced cancer. Medicine (Baltimore). 2019;98(37): e17019. Doi: 10.1097/MD.0000000000017019.
• ⁷ Guo ZQ, Yu JM, Wei W, Fu ZM, Lin Y, Shi YY, et al. Survey and analysis of the nutritional status in hospitalized patients with malignant gastric tumors and its influence on the quality of life. Support Care Cancer. 2020; 28(1): 373–380. Doi: 10.1007/s00520-019-04803-3.
• ⁸ Arends J, Strasser F, Gonella S, Solheim TS, Madeddu C, Ravasco P, et al. Cancer cachexia in adult patients: ESMO Clinical Practice Guidelines 2021; 6(3):100092. doi: 10.1016/j.esmoop.2021.100092.
• ⁹ Pressoir M, Desné S, Berchery D, Rossignol G, Poiree B, Meslier M. Prevalence, risk factors and clinical implications of malnutrition in French Comprehensive Cancer Centres. Br J Cancer. 2010 Mar 16;102(6):966-71. Doi: 10.1038/sj.bjc.6605578.
• ¹⁰ Paulsen Ø, Laird B, Aass N, Lea T, Fayers P, Kaasa S, Klepstad P. The relationship between pro-inflammatory cytokines and pain, appetite and fatigue in patients with advanced cancer. PLoS One. 2017 May 25;12(5): e0177620.
• ¹¹ Lipschitz, DA. Screening for nutritional status in the elderly. Prim Care. 1994; 21:55- 67.
• ¹² World Health Organization. Physical status: the use and interpretation of anthropometry. Geneva: World Health Organization; 1995. (Technical Report Series, 854).
• ¹³ Blackburn GL; Thornton PA. Nutritional assessment of the hospitalized patients. Medical Clinics of North America 1979; 63(5): 1103-1115.
• ¹⁴ Muniz AHR, Rosa KS da C, Resende JMD de, Sampaio SG dos SM, Oliveira LC de. Factors Associated with Karnofsky Performance Status and its Trajectory in the Last Month of Life in Patients with Terminal Cancer. [Fatores Associados ao Karnofsky Performance Status e sua Trajetória no Último Mês de Vida em Pacientes com Câncer Termina]. Rev Bras Cancerol [Internet]. 2023; 69(1):e-092754. Disponível em: https://rbc.inca.gov.br/index.php/revista/article/view/2754; [acesso em 15 out 2024]
  » https://rbc.inca.gov.br/index.php/revista/article/view/2754
• ¹⁵ Paiva C, Manfredini LL, Paiva B, Hui D, Bruera E. The Brazilian Version of the Edmonton Symptom Assessment System (ESAS) is a feasible, valid and reliable instrument for the measurement of symptoms in advanced cancer patients. PLoS One. Jul 2015. Doi: 10.1371/journal.pone.0132073
• ¹⁶ Pelissaro E, Damo CC, Alves ALS, Calcing A, Kumpel DA. Assessment of nutritional status in oncological elderly patients admitted to a high complexity hospital of the North of Rio Grande do Sul [Avaliação do estado nutricional em pacientes idosos oncológicos internados em um hospital de alta complexidade do Norte do Rio Grande do Sul]. Sci Med 2016;26(2):ID22972. doi:10.15448/1980-6108.2016.2.22972.
• ¹⁷ Ge T, Lin T, Yang J, Wang M. Nutritional status and related factors of patients with advanced lung cancer in northern China: a retrospective study. Cancer Manag Res. 2019; 11:2225-2231. doi: 10.2147/CMAR.S193567. eCollection 2019.
• ¹⁸ Deon, RG, Goldim, JR. Comparison between different nutritional assessment methods in institutionalized and non-institutionalized elderly [Comparação entre Diferentes Métodos de Avaliação Nutricional em Idosos Institucionalizados e não Institucionalizados]. Perspectiva, Erechim 2016; 40(149):63-71.
• ¹⁹ Oliveira, ST, Peixoto MI, Santos CM, Andrade MIS, Vasconcelos AA, Melo LS. Evaluation of the strength, performance and muscle mass of cancer patients and its relationship with subjective and anthropometric parameters [Avaliação da força, desempenho e massa muscular de pacientes oncológicos e sua relação com parâmetros subjetivos e antropométricos]. Nutrición Clínica y Dietética Hospitalaria. 2018;38(2):92-98. doi: 10.12873/382tatiane
• ²⁰ Lee ST, Lim JP, Tan CN, Yeo A, Chew J, Lim WS. SARC-F and modified versions using arm and calf circumference: Diagnostic performance for sarcopenia screening and the impact of obesity. Geriatr Gerontol Int 2024; 24: 182–188. doi: 10.1111/ggi.14758.
• ²¹ 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):1519-1535. doi: 10.1038/s41430-020-0629-0.
• ²² National Cancer Institute. Appetite loss and nutrition. Disponível em: https://www.cancer.gov/about-cancer/treatment/side-effects/appetite-loss/nutrition-hp-pdq#_104. [acesso em 06 fev 2025].
  » https://www.cancer.gov/about-cancer/treatment/side-effects/appetite-loss/nutrition-hp-pdq#_104
• ²³ Surwillo A, Wawrzyniak A. Nutritional assessment of selected patients with cancer. Rocz Panstw Zakl Hig 2013; 64(3):225-233.
• ²⁴ Duval PA, Vargas BL, Fripp JC, Arrieira IC de O, Lazzeri B, Destri K, Assunção MCF. Cancer Cachexia in Oncology Patients Hospitalized in an Interdisciplinary Home Care Program [Caquexia em Pacientes Oncológicos Internados em um Programa de Internação Domiciliar Interdisciplinar]. Rev Bras Cancerol [Internet]. 2021;56(2):207-12.
• ²⁵ Faller JW, Zilly A, Moura AC, Brusnicki PH. Multidimensional pain and symptom assessment scale for elderly people in palliative care. Cogitare Enferm [Internet]. 2016;21(2):1-9.
• ²⁶ Stumpf F, Keller B, Gressies C, Schuetz P. Inflammation and nutrition: friend or foe? Nutrients 2023;15(5):1159. doi:10.3390/nu15051159
• ²⁷ Cehreli R, Yavuzsen T, Ates H, Akman T, Ellidokuz H, Oztop I. Can inflammatory and nutritional serum markers predict chemotherapy outcomes and survival in advanced stage nonsmall cell lung cancer patients? BioMed Research International. 2019; 1-8.
• ²⁸ Sauders JJ, Temin S, Ghoshal A, Alesi ER, Ali ZV, Chauhan C, et al. Palliative care for patients with cancer: ASCO Guideline Update. J Clin Oncol 2024;42:2336-2357. doi: 10.1200/JCO.24.00542.

Edited by

• Edited by: Yan Nogueira Leite de Freitas
  undefined

Publication Dates

• Publication in this collection
  11 Aug 2025
• Date of issue
  2025

History

• Received
  24 Oct 2024
• Accepted
  25 Apr 2025