Nutritional status and skeletal muscle status in patients with head and neck cancer: Impact on outcomes

Abstract

Background Computed tomography (CT)-defined skeletal muscle depletion and malnutrition are demonstrated as poor prognostic factors in patients with head and neck cancer (HNC), however to date, have only been explored in isolation. We aimed to describe body composition profile and examine the impact of nutritional status as well as independently and concurrently occurring body composition features on overall survival, treatment completion, unplanned admissions and length of stay (LOS) in patients undergoing radiotherapy (RT) or chemoradiotherapy (CRT) of curative intent for HNC. Methods This work is a retrospective, observational study of patients who had completed treatment of curative intent for HNC. Scored Patient-Generated Subjective Global Assessment (PG-SGA) was used to determine nutritional status. Tissue-density data were derived at the third lumbar vertebra (L3) with sarcopenia and myosteatosis defined by published, sex-specific threshold values stratified by body mass index for skeletal muscle index (cm 2 /m 2 ) and skeletal muscle radiodensity (SMR, Hounsfield Unit). Results Pre-treatment data (n = 277: 78% male, mean (SD) age 60 (13) years) revealed the prevalence of malnutrition (24.9%), sarcopenia (52.3%), myosteatosis (82.3%), and concurrently occurring sarcopenia and myosteatosis (39.7%). Malnutrition was independently associated with reduced OS for patients with moderate [hazard ratio (HR) 2.57; 95% confidence interval (CI) 1.45-4.55, P = 0.001] and severe (HR 3.19; 95% CI 1.44-7.07, P = 0.004) malnutrition on multivariable analysis but not sarcopenia (HR 1.09; 95% CI 0.70-1.71), P = 0.700 or myosteatosis (HR 1.28; 95% CI 0.57-2.84), P = 0.500). Malnutrition was associated with treatment discontinuation (P < 0.001), not completing RT as planned (P < 0.001), unplanned hospital admission (P = 0.021), and greater LOS (P < 0.001). Skeletal muscle status features were associated with unplanned hospital admissions for those with no features (32%), with sarcopenia only (50%), myosteatosis only (25%), and concurrent sarcopenia and myosteatosis (50%), P < 0.001. Similarly, a clinically relevant greater median (Q1, Q3) LOS was observed for those with sarcopenia only [5 (3, 32)], myosteatosis only [10 (5, 30)], concurrent sarcopenia, and myosteatosis [14 (4, 33)] days vs. those with no features [3 (2, 11)] days, P = 0.2. Conclusions Malnutrition was a more powerful prognostic indicator than CT-defined skeletal muscle depletion and was independently associated with reduced OS in patients undergoing RT or CRT of curative intent for HNC. CT-defined skeletal muscle depletion studies should recognize the multifaceted nature of human body composition and also measure nutritional status using validated methods in order to move towards developing a typology of high risk criteria for this complex patient group.

The effectiveness of skeletal muscle evaluation at the third cervical vertebral level for computed tomography‐defined sarcopenia assessment in patients with head and neck cancer

“…Ideally, sarcopenia thresholds using both sex and BMI‐specific values should be derived specifically using a large population of HNC patients. Although this has not been established to our knowledge to date, the use of the Martin et al 25 thresholds has been demonstrated in an Australian population, with Findlay et al investigating the impact of depleted skeletal muscle on outcomes in a large cohort of 277 patients with HNC 42 …”

“…Several studies have previously recommended sex‐specific threshold values based on outcomes in HNC populations, however, do not include BMI stratification 37–40 . Although the Martin et al 25 thresholds were derived using a large population of patients with either lung or gastrointestinal cancers ( n = 1473), they have been applied to HNC populations by several authors 32,41–43 . Ideally, sarcopenia thresholds using both sex and BMI‐specific values should be derived specifically using a large population of HNC patients.…”

“…Although this has not been established to our knowledge to date, the use of the Martin et al 25 thresholds has been demonstrated in an Australian population, with Findlay et al investigating the impact of depleted skeletal muscle on outcomes in a large cohort of 277 patients with HNC. 42 As there is not currently a set standard threshold for classifying sarcopenia in cancer patients in general, or specifically patients with HNC, comparison between studies is difficult. In Australia, an estimated 67% of adults were overweight or obese in 2017-2018, 44 and as the majority of patients in the present study were overweight or obese (63%), using the thresholds that included BMI classification was appropriate.…”

Sarcopenia and its impact in head and neck cancer treatment

“…Not only SMI, but also other body (composition) features, e.g. myosteatosis (intramuscular adipose tissue) and BMI (sarcopenic obesity), alone, combined or in combination with nutrition status have a predictive and prognostic value in HNC patients undergoing (chemo)radiotherapy and should be considered in future sarcopenia research [34,38,63].…”

Measurement of Sarcopenia in Head and Neck Cancer Patients and Its Association With Frailty

“…Low SMM is a predictor for the risk of aspiration pneumonia in HNSCC patients receiving chemoradiation ( 78 ). Moreover, low SMM was found to be predictive for length of hospital stay and unplanned admission in HNC patients treated with (chemo)radiotherapy ( 79 ). Low SMM was also associated with long-term morbidity of (chemo)radiation like dysphagia, xerostomia and trismus ( 40 , 80 , 81 ).…”