THE VALIDATION OF SELECTED MALNUTRITION IDENTIFICATION TOOLS AMONG BREAST AND COLORECTAL CANCER PATIENTS

Abstract

Background: Cancer is highly associated with malnutrition, either caused by the disease itself or due to anticancer therapy such as surgery, radiotherapy, or chemotherapy. Breast and colon cancers were the most common cancers in Malaysia in 2018, with 17.3% of breast cancer and 14% of colorectal cancer and surgical treatment remains the main treatment modality with good outcomes. These two types of cancer can set as proxies to other type of cancers. Prevalence of malnutrition has been reported to be between 20% to 80% from local and overseas studies. Early identification of malnutrition in cancer patients will enhance the post-treatment recovery process of cancer patients. Currently, the dietitians in Malaysia use the Subjective Global Assessment (SGA) or single nutrition indicators such as weight loss, dietary intake, and body composition in the diagnosis of malnutrition. Recently, newer comprehensive malnutrition screening tools have been developed to provide a more holistic assessment of malnutrition in an objective matter such as the AND/ASPEN malnutrition clinical characteristics and Global Leader Initiative on Malnutrition (GLIM). The studies using AND/ASPEN and GLIM and breast and colorectal cancer patients in Malaysian population is still lacking and there is no ideal tool that is up to date for malnutrition assessment among patients diagnosed with cancer. Our study aims to validate the newer composite malnutrition identification tools AND/ASPEN and GLIM against the well-established tool of SGA and determine their concurrent and predictive validity in breast and colon cancer patients undergoing elective surgery. Method: A validation study was conducted among 89 patients diagnosed with breast (n=46) and colon cancers (n=43) were recruited from Hospital Tuanku Jaafar, Seremban. Patients who were diagnosed with breast cancer and colorectal cancer between December 2018 to February 2020 were recruited in the Surgical Outpatient Department (SOPD). The recruited patients were explained on the study protocol and procedure. Consent form was signed before screening for eligibility. The composite malnutrition assessment tools used in determining the prevalence of malnutrition were SGA, AND/ASPEN, GLIM. SGA is a commonly used nutrition assessment tool in clinical setting, which used as a comparative standard in the study. SGA consists of weight changes, dietary intake changes, gastrointestinal symptoms which persists for 2 weeks, functional impairment, metabolic demand, nutrition focus physical findings on subcutaneous fat loss, muscle wasting, oedema and ascites were collected through physical examination. AND/A.S.P.E.N, which is a malnutrition clinical characteristics consensus consists of 6 different nutrition characteristics, include dietary intake changes, weight changes, muscle loss, fat loss, signs of oedema and reduced handgrip strength. GLIM recommends on the combination of at least 1 phenotypic criterion and 1 etiologic criterion to be presented in an individual for the diagnosis of malnutrition. The phenotypic criteria include weight loss, low BMI, and reduced muscle mass, while etiologic criteria include reduced food intake and assimilation as well as inflammation. Besides, the single nutrition indicators used were body mass index (BMI), handgrip strength, unintentional weight loss, sarcopenia, low energy intake and protein intake. Concurrent validation of the tools and indicators were analysed using Cohen’s kappa, sensitivity, specificity and ROC area under the curve. The predictive validation of the tools was analysed based on the odds ratio of malnutrition against the extended length of hospital stay (>5 days). P-value of less than 0.05 was categorised as having a significant association. Result: Most of the patients were Malay (57.3%), followed by patients of Chinese (24.7%) and Indian (18.0%) ethnicities. Most of them were married (86.5%), received formal education up to secondary school (48.3%). Most of the patients were categorised as having a low socioeconomic status (monthly household income of < RM 4,850), which was classified as B40 (89.9%). The patients were mostly diagnosed with stage II cancer, with other comorbidities such as diabetes mellitus, hypertension, and cardiovascular disease. The prevalence of malnutrition was 32.6%, 51.7% and 28.1% based on SGA, AND/ASPEN and GLIM, respectively. AND/ASPEN showed moderate agreement (k=0.445) and GLIM showed fair agreement (k=0.204) against SGA. Unintentional weight loss showed moderate agreement (k=0.438) and other single nutrition indicators showed no to fair agreement against SGA. AND/ASPEN showed good diagnostic ability (AUC=0.756), GLIM and other single nutrition indicators showed low to no diagnostic ability for malnutrition in comparison with SGA. Malnutrition based on composite nutrition assessment tools and single nutrition indicators were not significantly associated with an extended length of hospital stay after surgery. Conclusions: The prevalence of malnutrition differs according to the assessment tools used, with SGA identified 32.6% of malnutrition, GLIM identified 28.1% of patients as malnourished and AND/ASPEN identified 51.7% of the patients as malnourished. The AND/ASPEN tool would be a recommendation for assessing nutrition status among breast and colorectal cancer patients. Further validation study in different diseases populations with a larger sample size would be recommended.