Computed tomography diagnosed cachexia and sarcopenia in 725 oncology patients: is nutritional screening capturing hidden malnutrition?

Abstract

BackgroundNutrition screening on admission to hospital is mandated in many countries, but to date, there is no consensus on which tool is optimal in the oncology setting. Wasting conditions such as cancer cachexia (CC) and sarcopenia are common in cancer patients and negatively impact on outcomes; however, they are often masked by excessive adiposity. This study aimed to inform the application of screening in cancer populations by investigating whether commonly used nutritional screening tools are adequately capturing nutritionally vulnerable patients, including those with abnormal body composition phenotypes (CC, sarcopenia, and myosteatosis).MethodsA prospective study of ambulatory oncology outpatients presenting for chemotherapy was performed. A detailed survey incorporating clinical, nutritional, biochemical, and quality of life data was administered. Participants were screened for malnutrition using the Malnutrition Universal Screening Tool (MUST), Malnutrition Screening Tool (MST), and the Nutritional Risk Index (NRI). Computed tomography (CT) assessment of body composition was performed to diagnose CC, sarcopenia, and myosteatosis according to consensus criteria.ResultsA total of 725 patients (60% male, median age 64 years) with solid tumours participated (45% metastatic disease). The majority were overweight/obese (57%). However, 67% were losing weight, and CT analysis revealed CC in 42%, sarcopenia in 41%, and myosteatosis in 46%. Among patients with CT‐identified CC, the MUST, MST, and NRI tools categorized 27%, 35%, and 7% of them as ‘low nutritional risk’, respectively. The percentage of patients with CT‐identified sarcopenia and myosteatosis that were categorised as ‘low nutritional risk’ by MUST, MST and NRI were 55%, 61%, and 14% and 52%, 50%, and 11%, respectively. Among these tools, the NRI was most sensitive, with scores <97.5 detecting 85.8%, 88.6%, and 92.9% of sarcopenia, myosteatosis, and CC cases, respectively. Using multivariate Cox proportional hazards models, NRI score < 97.5 predicted greater mortality risk (hazard ratio 1.8, confidence interval: 1.2–2.8, P = 0.007).ConclusionsHigh numbers of nutritionally vulnerable patients, with demonstrated abnormal body composition phenotypes on CT analysis, were misclassified by MUST and MST. Caution should be exercised when categorizing the nutritional risk of oncology patients using these tools. NRI detected the majority of abnormal body composition phenotypes and independently predicted survival. Of the tools examined, the NRI yielded the most valuable information from screening and demonstrated usefulness as an initial nutritional risk grading system in ambulatory oncology patients.

Cancer‐Associated Malnutrition and CT‐Defined Sarcopenia and Myosteatosis Are Endemic in Overweight and Obese Patients

“…Sarcopenia and myosteatosis were equally prevalent across different levels of nutrition risk as evidenced by the low AUC scores of 0.56 and 0.57, respectively. Our results are concordant with those of Ni Bhuachalla et al, 19 who evaluated the prevalence of CT-defined sarcopenia and myosteatosis according to different levels of nutrition risk assigned by the MST, MUST, and NRI screening tools in a heterogeneous sample of advanced cancer patients from all BMI classes. The AUC for all 3 of these tools did not exceed 0.6.…”

“…Sarcopenia and myosteatosis defined by CT cannot be identified by any 1 of 4 nutrition risk screening tools commonly used in oncology (eg, PG-SGA SF, MST, MUST, or NRI). 19,26 The domains evaluated within currently available nutrition screening tools do not adequately capture features such as sarcopenia or myosteatosis. It is not known how to best screen for sarcopenia or myosteatosis in the oncology setting, and no tools have been developed specifically for use in cancer patient populations.…”

“…7,8,14,17,18 There is no consensus regarding which nutrition risk screening tool offers optimal detection of patients at risk of cancer-associated malnutrition, and nutrition risk screening in overweight and obese patients has not be well characterized. 9 Ni Bhuachalla et al 19 recently demonstrated that CT-defined sarcopenia and myosteatosis were prevalent in advanced cancer patients across all BMI classes, and these features were not captured by different levels of nutrition risk assigned by the Malnutrition Universal Screening Tool (MUST), the Malnutrition Screening Tool (MST), or the Nutrition Risk Index (NRI). While these tools were not specifically developed to detect patients with sarcopenia or myosteatosis, it is of interest to clinical practice to understand and create awareness about the extent to which these occult features, associated with poor clinical outcomes, exist in patients with different degrees of nutrition risk.…”

Is cachexia associated with chemotherapy toxicities in gastrointestinal cancer patients? A prospective study

“…Patients' nutritional status at baseline was similar with other studies in the literature which indicate BMI adequacy and considerable frequencies of sarcopenia and cachexia. As observed in other studies, this panorama reflects the increasing rates of overweight/obesity in this population and proposed that less importance should be placed on BMI . All patients classified with cachexia in the present study had weight loss higher than 5% in the previous 6 months.…”

“…As observed in other studies, this panorama reflects the increasing rates of overweight/obesity in this population and proposed that less importance should be placed on BMI. 33 All patients classified with cachexia in the present study had weight loss higher than 5% in the previous 6 months. However, considering only weight loss to define cachexia can be inadequate, as this fails to account for fluid accumulation, large tumour burden, and the fat visceral organ atrophy present in patients with cancer.…”