Among 506 hospitalised patients with cancer at nutritional risk, individualised nutritional support reduced the risk for mortality as compared to standard hospital food. The findings from a preplanned secondary analysis of a prospective, randomised, multicentre Effect of early nutritional support on Frailty, Functional Outcomes and Recovery of malnourished medical inpatients Trial (EFFORT), conducted in Switzerland, are published on 18 May 2021 by Prof. Philipp Schuetz of the Kantonsspital Aarau in Aarau, Switzerland and colleagues in the Annals of Oncology.
Malnutrition affects around 30% of patients with solid and haematological malignancies. It is associated with higher mortality, impaired functional status and longer hospital stays. The clinical presentation of malnutrition in patients with cancer may vary from loss of appetite and/or weight, to loss of muscle mass with sarcopenia, to severe tumour cachexia.
Several factors put patients with cancer at high malnutrition risk including tumour-derived cytokine release causing loss of appetite and anorexia, and side-effects of cancer treatment interfering with appetite and normal food intake.
When admitted to the hospital, patients with cancer are at high risk for further deterioration of the nutritional status due to fasting for diagnostic studies, treatment side-effects and overall suboptimal nutritional management.
Different screening tools are recommended, including the Nutritional Risk Screening (NRS 2002). The authors wrote in the background that there is relatively little evidence regarding this recommendation for the population of hospitalised patients with cancer. Previous data has been somewhat inconclusive.
While some studies looking at patients with colorectal cancer found improved outcomes associated with nutritional support interventions, other studies have not provided evidence in favour of using nutritional interventions. Whether malnutrition is indeed a modifiable risk factor and improved by nutritional interventions has therefore been questioned.
In the preplanned secondary analysis of patients with cancer included in the EFFORT study, the Swiss investigators compared protocol-guided individualised nutritional support (intervention group) to standard hospital food (control group) regarding mortality at 30-day (primary endpoint) and other clinical outcomes.
The study investigators analyzed 506 hospital admitted patients at nutritional risk with a diagnosis of lung cancer (n = 113), gastrointestinal tumours (n = 84), haematological malignancies (n = 108) and other types of cancer (n = 201).
Nutritional risk based on NRS 2002 was an independent predictor for mortality over 180 days with an age-, sex-, centre-, type of cancer-, tumour activity- and treatment-adjusted hazard ratio of 1.29 (95% confidence interval [CI] 1.09-1.54; p = 0.004) per point increase in NRS.
In the 30-day follow-up period, 50 patients (19.9%) died in the control group compared to 36 (14.1%) in the intervention group resulting in an adjusted odds ratio of 0.57 (95% CI 0.35-0.94; p = 0.027).
Interaction tests did not show significant differences in mortality across the cancer type subgroups. Nutritional support also significantly improved functional outcomes and quality of life (QoL) measures.
The study team concluded that nutritional risk in patients with cancer was an independent prognostic indicator regarding 6-month mortality. In patients with cancer and increased nutritional risk, individualised nutritional support reduced mortality. Nutritional support also improved functional and QoL outcomes.
The authors commented that their study support malnutrition screening upon hospital admission followed by an individualised nutritional support strategy in this vulnerable patient population. The study data strengthen the evidence in favour of inclusion of nutritional care in the multiprofessional and multidisciplinary management of patients with cancer and in relevant guidelines.
This work was supported by grants from the Swiss National Science Foundation and the Forschungsrat of the Kantonsspital Aarau.
Bargetzi L, Brack C, Herrmann J, et al. Nutritional support during the hospital stay reduces mortality in patients with different types of cancers: secondary analysis of a prospective randomized trial. Annals of Oncology; Published online 18 May 2021. DOI: https://doi.org/10.1016/j.annonc.2021.05.793