Sarcopenia as a predictor of nutritional status and comorbidities in hospitalized patients with cancer: A cross-sectional study

doi:10.1016/j.nut.2019.110703

Nutrition

Volume 73, May 2020, 110703

https://doi.org/10.1016/j.nut.2019.110703 Get rights and content

Highlights

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Of hospitalized patients with cancer, 40% were at risk of sarcopenia.
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Sarcopenia predicts poor nutritional status in hospitalized patients with cancer.
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SARC-F, Charlson Comorbidity Index, and Nutrition Risk Screening 2002 are good, fast, and useful approaches for screening in a hospital clinical routine.
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Screening of sarcopenia should be evaluated in hospitalized patients with cancer.

Abstract

Objectives

Sarcopenia promotes worsening of nutritional status and an increase in comorbidities. Likewise, use of validated instruments to assess nutritional and comorbidity factors are warranted. Thus, the objectives were to assess the prevalence of risk for sarcopenia and to determine whether there is an association between sarcopenia and nutritional status and comorbidities in hospitalized patients with cancer.

Methods

This was a cross-sectional study with 77 patients with different types of cancer. Both men and women were enrolled. The risk for sarcopenia was assessed by the Strength, Assistance With Walking, Rise From a Chair, Climb Stairs, and Falls (SARC-F) questionnaire. Patients were divided into two groups: risk for sarcopenia (SARC-F score ≥4) and no risk for sarcopenia (SARC-F score <4). The presence of comorbidities and nutritional risks were analyzed using Charlson Comorbidity Index (CCI) and Nutrition Risk Screening 2002 (NRS-2002), respectively. Logistic and multiple regression analyses were used to verify the association and predictive factors of SARC-F.

Results

Of the 77 patients, 40.2% (n = 31; 63.48 ± 10.59 y of age) were classified as having a risk for sarcopenia and 59.7% (n = 46; 51.20 ± 12.81 y of age) without risk. We found an association between the risk for sarcopenia and CCI and NRS-2002 in crude model and after adjustment for age. Additionally, SARC-F is a good predictor of the increase of CCI (β = 0.357, R² = 0.29, P = 0.003) and NRS-2002 (β = 0.519, R² = 0.49, P < 0.001).

Conclusion

In the present study, ∼40% of patients with cancer had a risk for sarcopenia and a greater prediction for nutritional risk (49%) and comorbidities (29%).

Introduction

Sarcopenia is a skeletal muscle disorder characterized by reduced muscle mass and functional capacity. It is common among older adults but also can occur in younger patients. Sarcopenia is associated with high treatment and care costs owing to malnutrition and its relationship with other comorbidities [1].

Although sarcopenia affects 24% to 41% of patients with cancer [2,3], there are a few studies in Brazil that have evaluated the association of sarcopenia with nutritional risk and comorbidities from the use of accessible, fast, and low-cost tools for clinical practice, as is the case of the Strength, Assistance With Walking, Rise From a Chair, Climb Stairs, and Falls (SARC-F) [4] and Charlson Comorbidity Index (CCI) and Nutritional Risk Screening 2002 (NRS-2002) [5].

Recently, the European Working Group on Sarcopenia in Older People consensus recommended the use of the SARC-F in clinical practice for screening patients for the risk for sarcopenia [1], as this instrument has been validated previously [4]. Studies with patients with cancer indicate that the evaluation of sarcopenia and its outcomes, using screening tools such as SARC-F, is able to identify early changes in health status [6,7]. A previous study conducted by our group involved patients with cancer of the gastrointestinal tract and found that those at higher risk for sarcopenia had greater presence of anxiety [6].

In southern Brazil, prevalence of muscle function loss using the SARC-F is ∼40% in the older population >60 years old [4]. In the Midwest section of Brazil, this number can reach up to 25% of patients with cancer [6]. Additionally, its prevalence is around 19% in China, 41% in Japan, 34% in Austria, and 24% in Ireland [2,3,[7], [8], [9]].

CCI scores in middle age and elderly patients with cancer have shown that an increased score is associated with intrahospital mortality in the postoperative period and with the presence of preoperative sarcopenia [9]. Additionally, the classification of CCI can predict mortality rates during a whole year, that is, a classification of 0 predicts in 12%, 1 to 2 in 26%, 3 to 4 in 52%, and ≥5 in 85% [10].

Considering that the presence of sarcopenia can compromise an individual's state of health, reduce their quality of life, and increase mortality [1], the use of validated and easily applied methods for screening of sarcopenia risk is important in daily clinical practice [11]. Additionally, the present study highlighted the importance between screening for sarcopenia risk and confirmation of diagnosis using the bioelectrical impedance analysis as a recommended method. Therefore, we hypothesized that the SARC-F questionnaire is a predictor of nutritional status and comorbidities. Thus, the aims of this study were to evaluate the prevalence of sarcopenia risk and verify the association between sarcopenia and nutritional status, and comorbidities in hospitalized patients with cancer.

Section snippets

Study design and population

This was a cross-sectional study conducted with 77 patients (45 men and 32 women) who were admitted to the Clinical Hospital at the Federal University of Goiás for medical treatment. Inclusion criteria were patients of both sexes, with any type of cancer, age ≥18 y, and undergoing clinical or surgical treatments. The study was approved by the Research Ethics Committee and all patients signed a consent form in accordance with the National Health Council.

Clinical data and anthropometric evaluation

Socioeconomic and clinical data were

Results

The clinical characteristics of the patients are described in Table 1. During the screening for sarcopenia, 59.7% of the patients did not show risk for sarcopenia (SARC-F <4); however, 40.3% did, with SARC-F scores ≥4. When confirmed by BIA, 61.5% presented probable sarcopenia and 38.5% sarcopenia (Supplementary Fig. 1).

Patients with higher SARC-F scores also presented higher CCI (SARC-F <4: 3.43 ± 1.24 versus SARC-F ≥4: 5.06 ± 2.03, P = 0.0002), higher NRS (SARC-F <4: 2.09 ± 1.17 versus SARC-F

Discussion

The main finding of the present study was that ∼40% of patients had a risk for sarcopenia, and presence of sarcopenia was able to predict comorbidities in 29% and nutritional risk in 49%. Thus, the SARC-F questionnaire seems to be an important tool in the early detection of sarcopenia risk and to predict the presence of comorbidities and worsening of the nutritional prognosis in hospitalized patients with cancer.

Results from Vashi et al.’s study [3] agree with the present study. They found a

Conclusions

Of patients with cancer, 40% presented a sarcopenia risk. The SARC-F screening was able to predict the presence of comorbidities in 29% and in 49% the variations in nutritional status.

Acknowledgment

TCB acknowledges CAPES, Brazil.

Declaration of competing interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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Muscle function loss is associated with anxiety in patients with gastrointestinal cancer
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Low skeletal muscle mass outperforms the Charlson Comorbidity Index in risk prediction in patients undergoing pancreatic resections
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This study sought to evaluate the association between Charlson Comorbidity Index (CCI) and neutrophil lymphocyte ratio (NLR). Cross-sectional study evaluated 134 patients of both sexes diagnosed with several types of cancer. NLR was calculated by dividing the absolute value of neutrophils by lymphocytes count, and the CCI questionnaire was used to assess the risk of comorbidities and mortality. The sample was dichotomized in CCI < 5 or ≥5. Student's t-test and Chi-square test were calculated to analyze the differences. The association between CCI and NLR was investigated by logistic regression analysis, performed with model 1 (crude) and model 2 (adjusted). The patients in the CCI ≥ 5 group were older, with higher neutrophil levels and prevalence of solid tumor type. There was no difference between groups regarding type of treatment, body weight, body mass index, performance status, lymphocyte count and NLR. There was no association between CCI and NLR, in both crude model (OR: 1.04 [95% CI: 0.99–1.09], p = 0.09), as well as adjusted for sex, age, physical activity, alcohol consumption, smoking habit, type of treatment, and performance status (OR: 1.04 [95% CI:0.97–1.12], p = 0.19). In hospitalized unselected cancer patients, despite of small sample size and design of study, we showed the presence of comorbidities is not related to the NLR.
High Charlson comorbidity index value is not associated with muscle strength in unselected cancer patients
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Our results are similar with other findings in cancer patients who presented reduced muscle strength [3,24] and increased number of comorbidities [4]. We also found that patients with more comorbidities had higher score in the SARC-F questionnaire, which was observed in previous studies in our group, where we found that patients with risk for sarcopenia are more likely to develop comorbidities [11]. Indeed, is knowing that cancer patients have less muscle strength and greater CCI, and therefore an increased risk of morbidity and mortality [3,18,25].
Cancer patients usually lose muscle mass and strength during progression of tumor or treatment. One of the simplest, easiest, and cheapest methods to assess muscle strength is by handgrip strength (HGS), which has been widely used during clinical practice. However, it is not established whether the presence of comorbidities, when assessed by the Charlson Comorbidities Index (CCI), is associated with lower HGS in cancer patients. Thus, this study sought to verify if low HGS is associated with highest CCI in cancer patients.
Cross-sectional study enrolled 167 cancer patients of both sexes diagnosed with cancer. The sample was divided into two groups, CCI <5: low comorbidity or CCI ≥5: high comorbidity number. Muscle strength was assessed by digital dynamometer. Student t and Chi-square tests were performed to analyze the differences between groups and logistic regression was used to verify the association between CCI and HGS, in the crude (model 1) and adjusted for confounding variables (model 2).
Patients from the CCI ≥5 group were older (65.0 ± 11.3 vs. 55.3 ± 13.1; p < 0.05), hospitalized (p < 0.05), and the gastrointestinal and accessory organs of digestion tumors were more prevalent when compared to the CCI <5 group. The logistic regression in the crude model showed a negative association between CCI and HGS (OR: 0.94 [95%CI: 0.90–0.98], p = 0.006), however, after adjusting for confounders variables this association was lost (OR: 0.98 [95%CI: 0.94–1.03], p = 0.58).
In patients with cancer, there is no independent association between HGS and CCI.
Reliability and Concurrent Validity of the SARC-F and Its Modified Versions: A Systematic Review and Meta-Analysis
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A total of 3915 articles were screened for titles and abstracts, and 82 articles were identified for full-text screening. Twenty-nine articles37–65 were included in this systematic review (Supplementary Figure 1). Eleven authors were contacted, of which 7 responded.
Sarcopenia, being prevalent in up to 40% of older adults, is associated with adverse health outcomes. The international sarcopenia guidelines recommend screening for sarcopenia using the SARC-F. A previous meta-analysis (2017) reported poor validity of the SARC-F among community-dwelling older adults. Since then, modified SARC-F versions were developed and new sarcopenia definitions were published, including the SARC-F for case-finding. This systematic review and meta-analysis aimed to assess the reliability of the SARC-F and its concurrent validity to identify sarcopenia.
Systematic review and meta-analyses.
Adults (all ages) from any study population.
A systematic search was conducted in MEDLINE, EMBASE, Cochrane, and CINAHL (January 1, 2013, to April 6, 2020). Articles were included if they reported on the reliability and/or concurrent validity of the (modified) SARC-F. No restrictions were applied for sex, age, study population, or sarcopenia definition. Reliability measures included inter-rater reliability, test-retest reliability, and internal consistency. Meta-analyses were performed for concurrent validity.
The 29 included articles included 21,855 individuals (mean age of 63.3±14.6 years, 61.3% females) among community-dwelling (n = 16), geriatric inpatient (n = 5), geriatric outpatient (n = 2), nursing home (n = 2), and long-term care (n = 1) populations. The SARC-F had good (2/4 articles) to excellent (2/4 articles) inter-rater reliability, moderate (1/6 articles) to good (5/6 articles) test-retest reliability, and low (4/8 articles) to high (4/8 articles) internal consistency. The SARC-F had low to moderate sensitivity (28.9%-55.3%) and moderate to high specificity (68.9%-88.9%) according to the European Working Group on Sarcopenia in Older People (EWGSOP; n = 13), revised EWGSOP definition (EWGSOP2; n = 6), Asian Working Group for Sarcopenia (AWGS; n = 13), Foundation for the National Institutes of Health (FNIH; n = 8), International Working Group on Sarcopenia (IWGS; n = 9), and Society on Sarcopenia, Cachexia and Wasting Disorders (n = 2). The SARC-CalF had low to moderate sensitivity (45.9%-57.2%) and high specificity (87.7%-91.3%) according to the EWGSOP (n = 5), AWGS (n = 4), FNIH (n = 3), and IWGS (n = 3).
Despite the good reliability of the SARC-F, its low to moderate sensitivity and moderate to high specificity make it nonoptimal to use for sarcopenia screening. It is recommended to apply the diagnostic criteria for sarcopenia without screening.
Association of SARC-F and dissociation of SARC-F + calf circumference with comorbidities in older hospitalized cancer patients
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The Strength, Assistance for walking, Rise from a chair, Climb stairs and Falls (SARC-F) score is a tool recommended for screening the risk of sarcopenia in older patients. However, the association between SARC-F or SARC-F + calf circumference (SARC-F + CC) and the Charlson Comorbidity Index (CCI) in hospitalized older cancer patients is not fully understood. Thus, our aim is to evaluate the association between the SARC-F or SARC-F + CC and the presence of comorbidities and risk of death in older hospitalized cancer patients. A cross-sectional study involving 90 (42 M/48F) hospitalized cancer patients over 60 years old with ongoing chemotherapy or surgical treatment is carried out. The SARC-F is performed to assess the muscle function loss (MFL if SARC-F ≥ 4), sarcopenia (SARC-F ≥ 6) and sarcopenia using the calf circumference (SARC-F + CC ≥11). CC is assessed using an inelastic tape. The CCI is used to assess the presence of comorbidities. Logistic regression is used to evaluate the association between the SARC-F and Charlson Comorbidity Index. Mean of age is 67.8 years and half (49%) of the patients present MFL (SARC-F ≥ 4), 31% present sarcopenia using the SARC-F ≥ 6 and 60% using the SARC-F + calf circumference ≥ 11. Although no association in the crude model, there is association after adjusting by age, sex, alcohol use, smoking habit, physical activity, use of oral nutritional supplementation, body mass index, performance status, tumor, and treatment type between SARC-F ≥ 4 or ≥ 6 and CCI (SARC-F ≥ 4 × CCI: OR: 2.31 [95%CI: 1.02–5.23], p = 0.04) and (SARC-F ≥ 6 × CCI: OR: 3.24 [95%CI: 1.21–8.65], p = 0.01), respectively. However, this association is lost when using the SARC-F + calf circumference (SARC-F + CC ≥11 × CCI: OR: 1.12 [95%CI: 0.63–1.90], p = 0.68). In conclusion, screening for the risk of sarcopenia in older cancer patients is highly recommended as sarcopenia is tightly associated with the clinical outcome. The use of the SARC-F score using a cut-off ≥4 or ≥ 6 is more relevant for clinical practice to detect comorbidities and risk of death than the use of SARC-F with the calf circumference.
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The final score can range from 0 to 10 points, and patients with a final SARC-F score ≥4 were classified as having sarcopenia [22]. This instrument has been validated in clinical practice during screening to verify the risk for sarcopenia [16] and used to predict worsening nutritional status in patients with cancer [13]. Samples size calculation was performed using the G*Power 3.1 software and a regression model, with an α error rate of 5% and a β error rate of 95%.
Individuals with cancer are affected by a loss of cell membrane integrity due to electrolyte imbalance between the intra- and extracellular fluids. Cell membrane integrity and hydration status can be assessed according to the phase angle (PhA) and the risk for sarcopenia, by using the Strength, Assistance for walking, Rise from a chair, Climb stairs, and Falls (SARC-F) questionnaire. To our knowledge, this approach has not been validated in patients with cancer. The aims of this study were to verify the prevalence of the risk for sarcopenia, and to analyze the association between PhA and the risk for sarcopenia with and without adjustment for extracellular water content.
This was a cross-sectional study conducted with 124 male and female cancer patients (77.4% men). PhA and hydration status were assessed using bioelectrical impedance analysis (BIA), and the risk for sarcopenia (cutoff ≥4) was assessed using the SARC-F questionnaire.
Of the 124 patients, 28 (22.5%) were at risk for sarcopenia (SARC-F ≥4). There was no association between PhA and the risk for sarcopenia in the crude model, nor in the model adjusted for age, sex, smoking, alcohol consumption, and physical activity, nor after adjusting for use of supplements, body mass index, treatment type, performance status, and type and stage of cancer. However, we found an association between lower PhA values and a higher risk for sarcopenia after adjusting for hydration abnormalities (odds ratio, 1.74; 95% confidence interval, 1.03–2.93; P < 0.035).
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SMI and sarcopenia are both considered new methods for nutritional assessment. They have attracted extensive research interest in the modern field of clinical nutrition for cancer patients [32]. Numerous studies demonstrated that reduced SMI and sarcopenia presence were significantly associated with negative clinical outcomes, such as increased complications and reduced disease-free survival and overall survival in patients with cancer [27,28,33–36], while increased SMI or reduced sarcopenia was significantly associated with improved clinical outcomes [5,37,38].
Guidelines on clinical nutrition recommend the use of appropriate nutritional support therapy for surgical cancer patients at risk of malnutrition both during hospital care and following discharge from the hospital. However, previous studies regarding nutritional interventions have mainly focused on patients during their hospital stay; there is limited evidence supporting the recommendation of nutritional interventions for post-discharge patients after cancer surgery, particularly those who underwent gastrointestinal cancer surgery and at high risk of malnutrition. To clearly address this issue, we designed and conducted two independent studies on two different groups of post-discharge patients at nutritional risk after gastrointestinal cancer surgery. The present study aimed to assess the impact of oral nutritional supplements (ONS) in post-discharge patients at nutritional risk following colorectal cancer surgery. Meanwhile, the sister study on the use of ONS in post-discharge patients following gastric cancer surgery will be reported separately.
Between January 2017 and June 2019, post-discharge patients following colorectal cancer surgery in our institution were randomised to receive either dietary advice alone (control group) or dietary advice in combination with ONS (ONS group) for three months if they were at nutritional risk based on the tool of Nutritional Risk Screening 2002. The primary endpoints were nutritional outcomes and sarcopenia prevalence. The secondary endpoints were 90-day readmission rate, chemotherapy tolerance, and quality of life (QoL).
Of the 232 eligible patients, 212 (107 in the control group and 105 in the ONS group) completed the trial. Their data were then analyzed. The mean ONS intake was 410 mL every day. By the three-month intervention, the skeletal muscle index in the ONS group was significantly higher than that in the control group (39.75 ± 5.83 vs 38.01 ± 6.18 cm²/m², P = 0.037), but no significant differences between the two groups were noted in weight, weight loss, body mass index, serum albumin and hemoglobin (P > 0.05). In addition, the ONS group had a significantly lower sarcopenia prevalence (28.6% vs 42.1%, P = 0.040). No significant difference between the two groups was found in the 90-day readmission rate (P > 0.05). The number of patients undergoing postoperative chemotherapy in the two groups was similar, but chemotherapy modifications, such as delay, dose reduction, or termination, were significantly reduced in the ONS group (21.2% vs 36.8%, P=0.024). However, ONS had no significant effect on QoL (P > 0.05).
In post-discharge patients at nutritional risk following colorectal cancer surgery, the use of ONS may reduce skeletal muscle loss and sarcopenia prevalence, as well as improve chemotherapy tolerance, compared with dietary advice alone. These findings underline the importance of ONS treatment in post-discharge patients at nutritional risk following colorectal cancer surgery.

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: TLNG participated in data collection. GDP and TCB performed the statistical analyses and discussed the data. All authors contributed to the writing of the manuscript. The authors have no conflicts of interest to declare.

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Applied nutritional investigationSarcopenia as a predictor of nutritional status and comorbidities in hospitalized patients with cancer: A cross-sectional study

Highlights

Abstract

Objectives

Methods

Results

Conclusion

Introduction

Section snippets

Study design and population

Clinical data and anthropometric evaluation

Results

Discussion

Conclusions

Acknowledgment

Declaration of competing interests

J Am Med Dir Assoc

Clin Nutr

Clin Nutr ESPEN

Eur J Surg Oncol

J Chronic Dis

J Am Med Dir Assoc

Applied nutritional investigation
Sarcopenia as a predictor of nutritional status and comorbidities in hospitalized patients with cancer: A cross-sectional study