Malnutrition in Older Cancer Patients

Xiaotao Zhang, The University of Texas School of Public Health


Background: Malnutrition is a common and underrecognized condition in older adults (65 years and older). Unfortunately, the consequences of undiagnosed malnutrition can be detrimental to the health of an older person. The underrecognition of malnutrition can lead to compromised immunity, unhealthy weight loss, reduced mobility, and ultimately, reduced independence. In hospital settings, the prevalence of malnutrition ranges between 20% and 50%, depending on the patient population, the definition of malnutrition, and diagnostic criteria. The incidence of malnutrition is even higher among older adult patients in cancer care institutions. The overall goal is to determine whether malnutrition affects the survival of older cancer patients in a retrospective cohort study of follow-up visits completed at the MD Anderson Cancer Center from 2013 to 2017. Methods: In this 4-year retrospective cohort study, patients receiving cancer care underwent a comprehensive geriatric assessment that included cognitive, functional, nutritional, physical, and comorbidity measurements. Malnutrition status was determined through the Mini Nutritional Assessment and clinical interviews. Patients received recommendations for nutritional supplementation, and when necessary, appetite stimulants. We determined the prevalence of malnutrition and used univariate and multivariable Cox regression survival analyses to assess the association between baseline malnutrition and survival. Results: A total of 454 patients with hematologic, gastrointestinal, urologic, breast, lung, and gynecologic cancers were included in the analysis. The median age was 78 years, range 65-96 years, and men and women were equally represented. Forty-two percent (n = 190) were malnourished at baseline, and 33% died during the follow-up (median follow up length is 15.6 months, range 0.2 to 51.1 month). For aim1: In the systematic review and meta-analysis: Ten studies met the inclusion criteria, and a total of 3,786 older cancer patients were included in the meta-analysis. Heterogeneity existed among the different studies (I2 = 80.2 %, p<0.01). Malnutrition was significantly positively associated with increased risk of overall mortality (RR: 2.08; 95% CI: 1.51-2.85) compared with patients with good nutrition status. In the MD Anderson retrospective cohort study: Univariate analysis showed that malnutrition increased the risk of all-cause mortality in all cancers (hazard ratio [HR], 1.47; 95% confidence interval [CI], 1.07-2.03; p = 0.02). In our final multivariate Cox regression model, after controlling for gender, age, major depression, age-adjusted Charlson Comorbidity Index score, cancer stage, living arrangement, frailty, and functional impairment, we determined that malnutrition increased the risk of all-cause mortality in older patients with cancer (HR, 1.64; 95% CI, 1.03-2.63; p = 0.04). For aim 2: During the CGA, 190 of the patients (41.9 %) were diagnosed with malnutrition. According to the MNA results, 105 of 352 (total available patients with MNA assessed) (30%) were categorized as malnourished, and 122 (35%) were found to be at risk for malnutrition. A weight loss > 3 kg was recorded for 183 out 358 patients (total available patients with weight loss information) (51%), and 30 of 454 patients (7%) had a BMI < 20 kg/m2. The MNA had good validity (sensitivity = 0.77, 95% CI: 0.72–0.83; specificity = 0.396, 95% CI: 0.93–0.99, area under curve (AUC) = 0.83) and reliability (κ = 0.67, 95% CI: 0.60–0.75) compared to the geriatric diagnosis. The validity and reliability of weight loss to predict malnutrition were both moderate compared with the geriatric diagnosis. The overall validity (AUC) was 0.73, the sensitivity was 0.69 (95% CI: 0.62–0.75), and the specificity was 0.78 (95% CI: 0.72–0.84). The κ for weight loss and geriatric diagnosis was 0.46 (95% CI: 0.37–0.55). BMI was found to have the lowest validity and reliability among the three screening tools. The overall validity (AUC) was only 0.55, with a higher sensitivity of 0.80 (95% CI: 0.66–0.94) but a low specificity of 0.61 (95% CI: 0.57–0.65). The κ for BMI < 20 kg/m2 and geriatric diagnosis was only 0.12, indicating very low reliability of BMI for predicting malnutrition. For aim 3: In the multivariable analysis, major depression and frailty remained significantly associated with malnutrition. After controlling for potential confounders, patients who had malnutrition were 2.53-times more likely to have major depression (OR = 2.53, 95% CI: 1.23–5.24, p = 0.01) and 3.82 times more likely to have frailty (OR = 3.82, 95% CI: 1.35–10.84, p = 0.01) than those without malnutrition. A receiver operating characteristic curve generated to evaluate the performance of the final model yielded an AUC of 0.73. Conclusions: In summary, MNA was found to be the most valid and reliable predictor for malnutrition when compared with clinical diagnosis, while weight loss and BMI exhibited unfavorable validity and reliability. (Abstract shortened by ProQuest.)

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Recommended Citation

Zhang, Xiaotao, "Malnutrition in Older Cancer Patients" (2018). Texas Medical Center Dissertations (via ProQuest). AAI10846801.