Quality is more important than quantity: pre-operative sarcopenia is associated with poor survival in advanced ovarian cancer

Abstract

BackgroundSarcopenia is prevalent among older patients with cancer and is associated with poor outcomes.ObjectiveTo explore the relationship between muscle mass, quality, and patient age with overall survival after surgery for advanced ovarian cancer.MethodsPatients with advanced stage (IIIC/IV) ovarian cancer who underwent primary cytoreductive surgery between January 2006 and July 2016 were included. Body composition measures were calculated from pre-operative CT imaging: skeletal muscle index (skeletal muscle index=skeletal muscle area normalized for height), skeletal muscle density, and skeletal muscle gauge (product of skeletal muscle index and skeletal muscle density). Each measure was transformed to a z-score and evaluated for association with risk of death using Cox proportional hazards models. Recursive partitioning was used to classify patients into homogeneous subgroups considering age and skeletal muscle gauge as predictors of overall survival.ResultsThe study included 429 patients (mean age 64.2 years). Increased age moderately correlated with decreased skeletal muscle gauge (r=−0.45). Decreasing skeletal muscle density and skeletal muscle gauge were significantly associated with increased risk of death; HR (95% CI) per 1-unit decrease in z-score of 1.24 (1.10 to 1.39) for skeletal muscle density and 1.27 (1.12 to 1.44) for skeletal muscle gauge. Associations were diluted after adjusting for age (1.13 (1.00 to 1.29) skeletal muscle density and 1.14 (0.99 to 1.30) skeletal muscle gauge). Recursive partitioning identified three subgroups: <60 years old, ≥60 years old with skeletal muscle gauge ≥937.3, and ≥60 years old with skeletal muscle gauge <937.3; median overall survival was 5.8, 3.3, and 2.3 years, respectively (p<0.001).ConclusionsSkeletal muscle gauge, a novel sarcopenia measure incorporating quantity and quality, was associated with poorer survival in patients with advanced ovarian cancer, particularly among patients older than 60. Expanding our knowledge of how sarcopenia relates to solid tumor outcomes among high-risk patients can modify our treatment approach.

Response to: Correspondence on “Quality is more important than quantity: pre-operative sarcopenia is associated with poor survival in advanced ovarian cancer” by Maccio and Madeddu

“…We agree that advanced ovarian cancer represents an excellent model for evaluating the mechanisms of sarcopenia because of the catabolic state created by the disease. Sarcopenia is associated with increased age and with poorer outcomes in patients with advanced cancer, as reinforced by our study2 and others. Maccio and Madeddu3 highlight the need to investigate the interplay of patient fixed factors (age and stage), tumor biology, and energetics.…”

Explainable machine learning model for predicting skeletal muscle loss during surgery and adjuvant chemotherapy in ovarian cancer

“…However, skeletal muscle loss occurs during treatment and compromises the survival outcomes. [2][3][4][5][6][7] Muscle loss can be overlooked and may not be identified by changes in body weight. 5 Therefore, muscles in these patients should be assessed to identify loss and target interventions to preserve and recover muscle.…”

“…8 Previous studies have revealed the usefulness of CT-based muscle measurements in patients with ovarian cancer. [3][4][5][6] However, the utility of such measurements may be limited in clinical practice because the required process is labour-intensive and time-consuming. 9 To assess changes in muscle, pre-and post-treatment CT scans should be processed by specific software, and the muscle is manually or semi-automatically segmented on a cross-sectional image at L3 to calculate the area of skeletal muscle.…”

“…The treatment for ovarian cancer is cytoreductive surgery with adjuvant or neoadjuvant chemotherapy. However, skeletal muscle loss occurs during treatment and compromises the survival outcomes 2–7 . Muscle loss can be overlooked and may not be identified by changes in body weight 5 .…”

Correspondence on “Quality is more important than quantity: pre-operative sarcopenia is associated with poor survival in advanced ovarian cancer” by Polen-De et al

“…We read with interest the study by Polen-De and colleagues 1 regarding the relationship of muscle quantity and quality with prognosis in patients with advanced ovarian cancer. They concluded that sarcopenia was associated with poorer survival, particularly among patients aged >60 years.…”