The Impact of NUTRItional Status at First Medical Oncology Visit on Clinical Outcomes: The NUTRIONCO Study

Abstract

Malnutrition affects up to 75% of cancer patients and results from a combination of anorexia and metabolic dysregulation. Metabolic and nutritional abnormalities in cancer patients can lead to cachexia, a multifactorial syndrome characterized by involuntary loss of skeletal muscle mass, systemic inflammation and increased protein catabolism. Cancer cachexia negatively affects patients' outcomes, response to anticancer treatments, quality of life, and survival. However, risk of malnutrition, and cachexia are still under-recognized in cancer patients. The Prevalence of Malnutrition in Oncology (PreMiO) study revealed that 51% of patients already had nutritional deficiencies at their first medical oncology visit. Here, we report the results of the subsequent retrospective, observational NUTRItional status at first medical oncology visit ON Clinical Outcomes (NUTRIONCO) study, aimed at assessing the impact of baseline nutritional and non-nutritional variables collected in the PreMiO study on the clinical outcomes of the same patients followed up from August 2019 to October 2021. We have highlighted a statistically significant association between baseline variables and patient death, rehospitalization, treatment toxicity, and disease progression at follow-up. We found a higher overall survival probability in the well-nourished general study population vs. malnourished patients (p < 0.001). Of major interest is the fact that patient stratification revealed that malnutrition decreased survival probability in non-metastatic patients but not in metastatic patients (p < 0.001). Multivariate analysis confirmed that baseline malnutrition (p = 0.004) and VAS score for appetite loss (p = 0.0104), in addition to albumin < 35 g/L (p < 0.0001) and neutrophil/lymphocyte ratio > 3 (p = 0.0007), were independently associated with the death of non-metastatic patients at follow-up. These findings highlight the importance of proactive, early management of malnutrition and cachexia in cancer patients, and in particular, in non-metastatic patients, from the perspective of a substantial improvement of their clinical outcomes.

Keywords: anorexia; awareness; cachexia; cancer; early management; malnutrition; outcomes; survival.

Figure 1

Distribution of tumor types (A), tumor stages (B), and metastatic status (C) in patients included in the PreMiO (n = 1952) and NUTRIONCO (n = 571) studies.

Figure 2

MNA^® score in patients included in the PreMiO (n = 1952) and NUTRIONCO (n = 571) studies (A) and nutritional status by tumor type as per MNA^® score in NUTRIONCO study patients (B).

Figure 3

Kaplan–Meier curves with the log-rank test applied for the estimation of survival probability over time and comparison between curves, respectively. Overall survival probability estimated in the whole study population of cancer patients on the basis of their nutritional status (A), overall survival probability estimated in metastatic cancer patients on the basis of their nutritional status (B), overall survival probability estimated in non-metastatic cancer patients on the basis of their nutritional status (C).

Figure 4

Multivariate analysis assessing the effect of independent variables on death of non-metastatic cancer patients (A) and forest plot of the independent variables (B). CI: Confidence interval; F: female; FAACT: Functional Assessment of Anorexia/Cachexia Treatment; HR: hazard ratio; M: male; MNA^®: Mini Nutritional Assessment; NLR: neutrophil/lymphocyte ratio; VAS: visual analog scale. Cut-off values: FAACT score ≤ 30 for anorexia; VAS score ≤ 70 for appetite loss representative of anorexia; MNA^® scores: malnourished <17; at risk of malnutrition, 17 to 23.5; well-nourished >23.5; albumin < 35 g/L for hypoalbuminemia; hemoglobin < 12 g/dL in females and <13 g/dL in males for anemia; NLR > 3 for systemic inflammation. Variables independently associated with patients’ death are highlight in bold.