REVIEW

View metadata, citation and similar papers at core.ac.uk brought to you by CORE
provided by Hanze UAS repository

CURRENT
OPINION Assessing nutritional status in cancer: role of the
Patient-Generated Subjective Global Assessment
Harriët Jager-Wittenaar a,b and Faith D. Ottery a,c

Purpose of review
The Scored Patient-Generated Subjective Global Assessment (PG-SGA) is used internationally as the
reference method for proactive risk assessment (screening), assessment, monitoring and triaging for
interventions in patients with cancer. This review aims to explain the rationale behind and data supporting
the PG-SGA, and to provide an overview of recent developments in the utilization of the PG-SGA and the
PG-SGA Short Form.
Recent findings
The PG-SGA was designed in the context of a paradigm known as ‘anabolic competence’. Uniquely, the
PG-SGA evaluates the patient’s status as a dynamic rather than static process. The PG-SGA has received
new attention, particularly as a screening instrument for nutritional risk or deficit, identifying treatable
impediments and guiding patients and professionals in triaging for interdisciplinary interventions. The
international use of the PG-SGA indicates a critical need for high-quality and linguistically validated
translations of the PG-SGA.
Summary
As a 4-in-1 instrument, the PG-SGA can streamline clinic work flow and improve the quality of interaction
between the clinician and the patient. The availability of multiple high-quality language versions of the
PG-SGA enables the inclusion of the PG-SGA in international multicenter studies, facilitating meta-analysis
and benchmarking across countries.
Keywords
anabolic competence, malnutrition, nutritional assessment, Patient-Generated Subjective Global
Assessment, screening

INTRODUCTION in various national guidelines for nutrition in oncol-

Diagnosis and treatment of malnutrition and dis- ogy, for example Australia, Brazil, The Netherlands
turbed metabolism are of critical importance in [3], United Kingdom [4] and the United States. It is
patients with cancer. Because of the disease and not, however, an oncology-specific instrument.
the effects of anticancer therapies, many patients
with cancer are at risk for malnutrition. Malnutrition
is associated with poorer prognosis and decreased a
Research Group Healthy Ageing, Allied Healthcare and Nursing, Hanze
quality of life [1]. Nutritional assessment serves as University of Applied Sciences, bDepartment of Maxillofacial Surgery,
the basis for the malnutrition diagnosis, which also University of Groningen, University Medical Center Groningen, Groningen,
includes cause, severity and type of malnutrition [2]. The Netherlands and cOttery & Associates LLC, Oncology Care
The Scored Patient-Generated Subjective Global Consultants, Greater Chicago Area, Greater Chicago, Illinois, USA
Assessment (PG-SGA; Copyright FD Ottery, 1996, Correspondence to Harriët Jager-Wittenaar, Research Group Healthy
2001, 2005, 2006 and 2015) is broadly used in both Ageing, Allied Healthcare and Nursing, Hanze University of Applied
Sciences, Eyssoniusplein 18, 9714 CE Groningen, The Netherlands.
clinical practice and in academic research as the
Tel: +31 623668897; e-mail: [email protected]
reference method for assessing the nutritional status
Curr Opin Clin Nutr Metab Care 2017, 20:322–329
of patients with cancer. One of the considerations
DOI:10.1097/MCO.0000000000000389
underlying this wide acceptance is the fact that the
PG-SGA is a 4-in-1 instrument: nutritional screen, This is an open access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0
assessment, interventional triage and an instrument (CCBY-NC-ND), where it is permissible to download and share the work
to monitor interventional success. The PG-SGA is provided it is properly cited. The work cannot be changed in any way or
recommended in various countries and/or included used commercially without permission from the journal.

www.co-clinicalnutrition.com Volume 20  Number 5  September 2017

 Role of PG-SGA in cancer Jager-Wittenaar and Ottery

predispose the patient to future malnutrition. The

KEY POINTS PG-SGA’s triaging system includes nutritional,
 The PG-SGA was designed in the context of a pharmacologic, exercise and other interventions to
paradigm known as ‘anabolic competence’ and facilitate proactive identification, prevention and
addresses a multimodality approach, including treatment of malnutrition in at-risk patients.
nutrition, hormonal milieu and exercise.

 The PG-SGA and PG-SGA Short Form cover all HISTORICAL BASIS
domains of the conceptual definitions of malnutrition, as
defined by ESPEN and ASPEN. The PG-SGA was developed as a modification of the
original clinician-generated subjective global assess-
 The PG-SGA and PG-SGA Short Form are validated ment (SGA) developed at the University of Toronto
and sensitive instruments that can easily be used as
by Drs. Jeejeebhoy, Baker and Detsky. The original
nutritional screen completed by patients (Short Form),
and as nutritional screen, assessment or monitoring SGA was based on the hypothesis that restoration of
instrument by trained professionals (full or Short Form). food intake can rapidly reduce the risks associated
with malnutrition. Specifically, it was hypothesized
 The PG-SGA facilitates interdisciplinary planning across that if nutrient intake can be restored to optimal
the patient’s cancer care continuum by triaging for
levels to meet requirements, the risk of compli-
interventions, for example dietitian, nurse, physician or
other relevant individuals in the clinical care process. cation is lower, even though the patient may be
still wasted and underweight. Changing from a
 The growing number of translated and culturally clinician-generated to patient-generated approach
adapted versions of the PG-SGA enables global meta- aimed to address patient-centric concerns, stream-
analysis of data, as well as benchmarks for malnutrition
line the clinic flow across the care continuum (inpa-
outcomes globally.
tient, outpatient, home care and palliative care) and
to optimize time for patient–clinician interaction.
As patients complete the form prior to interacting
with their clinician that is any professional who is
Since the introduction of the PG-SGA in the involved in the clinical care of the patients with
1990s [5], it has been validated and utilized in both patient self-identification of those issues that impact
cancer and non-cancer patient populations interna- him/her, clinic flow can be shortened with accom-
tionally. Numerous studies have shown the associ- panying improvement in quality and productivity
ation between PG-SGA scores and specific nutritional of interaction.
parameters, for example weight loss, BMI, skinfold The PG-SGA was originally developed as a one-
measures and hand grip strength [6]. Both earlier page instrument that globally assessed a patient in
and recent data have demonstrated the PG-SGA’s terms of nutritional risk and nutritional deficit and
ability to predict clinical outcomes, for example sur- was unscored. The PG-SGA was subsequently scored,
vival, postoperative complications, length of stay, to stimulate its use in clinical and clinical trial
quality of life and hospitalization costs (Table 1) settings and to limit interobserver variability. A
&& &
[7 ,8 ,9–13]. The PG-SGA is sensitive to changes in scoring system was developed based on combined
nutritional status over time, for example in response input from both medical/oncologic and nutritional
to nutritional interventions [14]. perspectives, with the following considerations
Recently, the PG-SGA (full and Short Form) has included, particularly for Boxes 1–4:
received new attention, particularly as a screening
instrument for nutritional risk or deficit. The PG-SGA (1) Patient perception and patient-reported con-
is often described as a nutritional assessment instru- cerns
ment to diagnose malnutrition, and a recent system- (2) Variables of risk for malnutrition or prediction
atic review showed that both the PG-SGA and of degree of nutritional deficit
PG-SGA Short Form (i.e. Boxes 1–4) cover all domains (3) Options for intervention for nutritional intake
of the conceptual definitions of malnutrition, as and nutrition impact symptoms to prevent
defined by the European Society for Clinical Nutri- or reverse malnutrition and weight loss, for
tion and Metabolism (ESPEN) and the American example behavioral, educational and pharmaco-
Society for Parenteral and Enteral Nutrition (ASPEN) logic interventions
&
[15 ]. Current interest also focuses on the PG-SGA’s (4) Known prognostic variables, such as degree and
ability to identify treatable impediments and to guide acuteness of weight loss and performance status,
patients and professionals in triaging for interdisci- for example a score of at least 2
plinary interventions. The PG-SGA not only ident- (5) A scoring schema of 0–4 points, consistent with
ifies existing malnutrition, but also risk factors that scoring used throughout oncology and in

1363-1950 Copyright ß 2017 The Author(s). Published by Wolters Kluwer Health, Inc. www.co-clinicalnutrition.com 323
Assessment of nutritional metabolic status

Table 1. Relationship between Patient-Generated Subjective Global Assessment scores and outcomes (n ¼ 1402), published
between 2015 and 2017
Year of
Author publication Setting Population (N) Outcomes

Rodrigues 2015 Hospital 146 women with Significant association between PG-SGA numerical score
et al. [7 ] gynecologic cancer (>10 points versus 0–10 points) and mortality within
&&

1 year [odds ratio ¼ 30.7; 95% confidence interval

(CI): 11.8–79.4]
Significant association between PG-SGA Categories and
mortality within 1 year (PG-SGA C versus A: hazard
ratio ¼ 2.04 95% CI: 1.03–4.05; P ¼ 0.041)
Significant association between PG-SGA Categories and
length of hospital stay [PG-SGA B (median length of stay
8.5 days; range 1–51 days) or C (median 12 days; range
2–32 days) versus A (median 7 days; range 2–17 days);
P ¼ 0.002]
Guerra et al. [8 ] 2016 University 637 hospitalized Significant association between PG-SGA Categories (PG-SGA
&

hospital patients (within C versus A) and increased hospitalization costs (27.5%;

72 h of admission) 95% CI: 14.0–41.1%; P < 0.001)
Hsieh et al.[9] 2016 Hospital 256 patients with Significant association between PG-SGA Categories (PG-SGA
metastatic gastric C versus A/B) and overall survival (hazard ratio ¼ 2.73;
cancer (within 1 95% CI: 1.73–4.29; P < 0.001)
week before start
of chemotherapy)
Barata et al. [10] 2017 Hospital 37 non-resectable Significant association between PG-SGA Categories (PG-SGA
lung cancer patients A, B/C) and hand grip strength (P ¼ 0.026; 95% CI:
0.023–0.029)
Härter et al. [11] 2017 Hospital 60 oncology patients Significant association between PG-SGA numerical score (4
admitted for versus 0–3 points) and severe postoperative complications
elective surgery (P ¼ 0.020)
Kim et al. [12] 2017 Hospital 216 patients with Significant association between PG-SGA numerical score (9
multiple myeloma versus 0–3 points) and overall survival (hazard
(prior to start of ratio ¼ 2.347; 95% CI: 1.271–4.334; P ¼ 0.006)
chemotherapy
El Ghammaz 2017 Hospital 50 patients Significant association between PG-SGA Categories (PG-SGA
et al. [12] undergoing B/C versus A) at admission (hazard ratio ¼ 21.542; 95%
allogeneic CI ¼ 1.163–399.076; P ¼ 0.039) and day 180 post-
hematopoietic stem transplantation (hazard ratio ¼ 281.879; 95% CI ¼ 1.642–
cell transplantation 48.399; P ¼ 0.032) and overall survival, respectively

toxicity criteria, indicating normal or minimal paradigm of anabolic competence depicts the
impact on nutritional status or risk (0); mild primary components of optimal interventions:
impact (1); moderate impact (2); severe impact nutrition, hormonal milieu (including classic
(3) and potentially life-threatening impact (4) hormones and cytokines) and exercise (Fig. 1).
(6) Total PG-SGA score predominantly from patient Although defined in the 1990s, this integrative
input rather than clinician evaluation approach is increasingly being appreciated as critical
in shaping how we think of intervention during
cancer treatment, particularly in the context of
ANABOLISM VERSUS CATABOLISM: THE optimizing oncologic outcomes and quality of
CORE TENET OF THE PATIENT- survivorship.
GENERATED SUBJECTIVE GLOBAL The PG-SGA addresses a multimodality and
ASSESSMENT interdisciplinary approach. The Boxes are comp-
The PG-SGA was designed in the context of a para- lementary to each other, as each addresses factors
digm known as ‘anabolic competence’, that is the that place the patient at risk for nutritional deficit or
state that optimally supports protein synthesis and poorer outcome. In addition, the PG-SGA includes
lean body mass, global aspects of muscle and catabolic factors hindering protein synthesis and
organ function and immune response [6]. The increase in lean body mass, for example fever and

324 www.co-clinicalnutrition.com Volume 20  Number 5  September 2017

 Role of PG-SGA in cancer Jager-Wittenaar and Ottery

term weight stabilization or weight gain, the MNA

does not ‘correct’ for recent improvements.

STRUCTURE OF THE PATIENT-GENERATED

Nutrional Exercise SUBJECTIVE GLOBAL ASSESSMENT
milieu
Opmal body The PG-SGA was early in adopting the concept that
composion
and
the patient – not the clinician or carer – is better at
physiologic reporting what she/he is experiencing. The PG-SGA
funcon empowers patients (and indirectly their carers)
by asking them about matters that can often be
overlooked, or that can be seen to be of lesser
importance. The PG-SGA identifies variables that
Hormonal patients may avoid addressing so as not to be seen
milieu as complainers; because they do not know that
intervention is possible; or because they believe that
©
Oery FD, 1998, 2002 the symptoms may mean the cancer is worsening or
returning. The variety of factors addressed by the
FIGURE 1. Anabolic competence: core tenet of the PG-SGA Boxes and Worksheets (Table 2) characterizes the
nutritional intervention. Anabolic competence is that state PG-SGA as a global assessment of patient risk, rather
which optimally supports protein synthesis and lean body than solely nutritional deficit.
mass, global aspects of muscle and organ function and The PG-SGA consists of two components. First,
immune response [8 ]. PG-SGA, Patient-Generated
&

the patient-generated component, that is Boxes 1–4

Subjective Global Assessment. (Fig. 2A), officially known and separately used as the
PG-SGA Short Form, was designed to be completed
by the patient and to reflect approximately 80–90%
the use of corticosteroids (Worksheet 3). Identifying of the score [5]. The PG-SGA Short Form has been
these catabolic factors has therapeutic implications: validated as independent screening tool [17]. Sec-
fever increases nutritional requirements correlated ond, the items in the professional component
with degree and duration of fever, and, depending (Fig. 2B) were developed as Worksheets to provide
on dose/route of administration/duration, the use self-contained training and to raise awareness of
of corticosteroids also increases protein require- contributors to malnutrition that in clinical practice
ments. Unfortunately, in daily practice, the use of may easily be overlooked, for example fever and
corticosteroids may be overlooked as a contributing corticosteroids [5]. The five Worksheets are com-
catabolic factor. pleted by the healthcare professional, which may
In contrast to other screening and assessment include the dietitian, nurse, physician, physiothera-
instruments, the PG-SGA evaluates the patient’s pist or others involved in the patient’s clinical care.
status as a dynamic rather than static process.
Although weight history is included in many
other screening and assessment instruments, the PATIENT-GENERATED SUBJECTIVE
PG-SGA uniquely uses weight history as an indicator GLOBAL ASSESSMENT AS 4-IN-1
of anabolism or catabolism. By scoring acute INSTRUMENT: SCREEN, ASSESSMENT,
weight change in addition to intermediate or TRIAGE AND MONITORING
chronic weight change, the PG-SGA distinguishes Although the PG-SGA has mostly been described as a
a ‘U-curved shape’ of weight from a linear decrease nutritional assessment tool [2], the PG-SGA should
in body weight. Addressing acute weight change be considered a 4-in-1 instrument: nutritional
characterizes the specificity of the PG-SGA as com- screen, assessment, interventional triage and an
pared to other screening and assessment instru- instrument to monitor interventional success. As
ments. In a recent Portuguese study, long-stay such, the PG-SGA has the advantage of not only
nursing home residents were evaluated by both being able to diagnose a problem, but also to effi-
PG-SGA and Mini Nutritional Assessment (MNA). ciently guide appropriate intervention and gauge
Interestingly, half of patients categorized as ‘Well improvement.
nourished’ by PG-SGA were categorized as ‘Risk of The inclusion of nutrition impact symptoms
malnutrition’ by MNA [16]. This discrepancy can be and other factors (Box 3) as risk factors may explain
explained by differences in the scoring of weight why the PG-SGA Short Form may categorize more
history: whereas the PG-SGA ‘corrects’ for short- patients at risk when compared to other screening

1363-1950 Copyright ß 2017 The Author(s). Published by Wolters Kluwer Health, Inc. www.co-clinicalnutrition.com 325
Assessment of nutritional metabolic status

Table 2. Explanation of the Patient-Generated Subjective Global Assessment’s Boxes and Worksheets

Box or Worksheet Explanation

Box 1 Chronic, intermediate and acute weight change

Box 2 Changes in amount/type/consistency of food intake
Box 3 Symptoms/impediments that negatively influence food intake/absorption/utilization of nutrients
Box 4 Activities and function based on the Eastern Cooperative Oncology Group (ECOG) performance status, converted to
layman’s language
Worksheet 1 Instructions on scoring of percentage weight loss (Box 1)
Worksheet 2 Conditions that may increase nutritional risk or requirements
Worksheet 3 Metabolic stress, for example fever (degree/duration) and corticosteroids (type/dose)
Worksheet 4 Scoring of muscle status (deficit/loss of muscle mass/tone), fat stores and fluid status, based on the nutrition-focused
physical examination
Worksheet 5 Overall patient global assessment categorization, utilizing the findings of Boxes 1–4 and the physical examination
(Worksheet 4). Categories: Stage A ¼ well nourished, or ‘not undernourished’; Stage B ¼ moderately malnourished
or suspected malnutrition; or Stage C ¼ severely malnourished

instruments. An exploratory study in Dutch head symptoms for which she/he does not receive timely
and neck cancer patients showed that 28% of intervention, nutritional status and quality of life
patients scored at least 9 points, and were con- are at risk for deterioration. Historically, studies
sidered ‘at high risk’ by the PG-SGA Short Form, utilizing the PG-SGA have predominantly been
compared to 21% categorized as ‘high risk’ accord- observational. Future clinical interventions trials
ing to the Malnutrition Universal Screening Tool should elucidate the impact of proactively address-
(MUST) or Short Nutritional Assessment Question- ing risk factors in the prevention of malnutrition or
naire (SNAQ). The PG-SGA Short Form also had stabilization of nutritional status.
better diagnostic accuracy than the MUST and The PG-SGA (full or Short Form) also facilitates
SNAQ, using the full PG-SGA as reference [18]. patient monitoring over time. The scoring of the
It is hypothesized that identifying nutrition PG-SGA (Table 3) was added to the PG-SGA
impact symptoms, especially in an early stage Categories to identify incremental changes in the
during the cancer continuum, may facilitate pro- patient’s global status. Earlier data from Australia
active malnutrition prevention. For example, a confirmed that a change in PG-SGA score of  9.0
patient may not have lost any significant weight points [95% confidence interval (CI): 7.2–10.9]
on the initial assessment with an Eastern Coopera- was required to change by one category (Stages A,
tive Oncology Group performance status of 0. If B or C) – improvement or deterioration – and
the patient checks off several nutrition impact showed that risk status may change even without

FIGURE 2. (a) Patient component of the PG-SGA, that is PG-SGA Short Form. (b) Professional component of the PG-SGA.
PG-SGA, Patient-Generated Subjective Global Assessment.

326 www.co-clinicalnutrition.com Volume 20  Number 5  September 2017

 Role of PG-SGA in cancer Jager-Wittenaar and Ottery

Table 3. Patient-Generated Subjective Global Assessment significant changes in the patient’s nutritional sta-
numerical scoring system tus. The PG-SGA point score is also the basis for
triaging for specific interdisciplinary interventions,
Score range
including patient education.
Boxes and Worksheets (points)

Box 1 – weight (maximum 5 points) – ADDITIVE

Self-reported weight change (1 month or 0–4 PRACTICAL CONSIDERATIONS ON THE
6 monthsa) USE OF THE PATIENT-GENERATED
Self-reported weight change in past 2 weeks 0–1 SUBJECTIVE GLOBAL ASSESSMENT
Box 2 – food intake (maximum 4 points) – highest score As 80–90% of the scoring results from the first four
Self-rated food intake during the past month 0–1 Boxes, it is consistent that the PG-SGA Short
Self-reported actual type of food intake 0–4 Form shows high sensitivity and specificity when
Box 3 – self-reported symptoms affecting eating (maximum compared to the full PG-SGA [17,18]. An Australian
24 points) – ADDITIVE study in ambulatory patients undergoing anticancer
No problems eating 0 treatment found a sensitivity and specificity of 80
No appetite, just did not feel like eating 3 and 72%, respectively, while using a PG-SGA Short
Nausea 1 Form risk cutoff score of at least 3 points [17]. A
Constipation 1 Dutch study in head and neck cancer patients that
Mouth sores 2 used a higher cutoff, that is at least 9 points, indi-
Things taste funny or have no taste 1 cating critical need for intervention as described in
Problems swallowing 2 the PG-SGA triage for nutritional recommendations,
Pain 3 showed a sensitivity and specificity of 73 and 100%,
Vomiting 3 respectively [18]. The good sensitivity and speci-
Diarrhea 3 ficity of the PG-SGA Short Form supports its use
Dry mouth 1 as screening and monitoring instrument.
Smells bother me 1 At the 2016 ESPEN Congress, it was articulated
Feel full quickly 1 that screening should use simple questions that can
Fatigue 1 be quickly answered by the patients, relatives or
Other 1
carers [19]. As early as the 1990s, the PG-SGA was
Box 4 – activities and function (maximum 3 points) – HIGHEST
reported as easy to use. Recent data collected during
SCORE the PG-SGA translation and cultural adaptation
Self-rated activity level 0–3 process to the Dutch setting confirmed that patients
Worksheet 1 – scoring weight loss – ADDITIVE consider the PG-SGA Short Form comprehensible
Is included in point score of Box 1 and easy [20]. The PG-SGA Short Form has also been
Worksheet 2 – disease and its relation to nutritional requirements
reported as a quick instrument to complete. It gener-
(no maximum) – ADDITIVE ally takes the patient less than 5 min, and this is
Cancer 1 often completed prior to seeing the healthcare pro-
AIDS 1 vider. Interestingly, the Dutch study in head and
Pulmonary or cardiac cachexia 1 neck cancer patients also showed that completing
Chronic renal insufficiency 1 the PG-SGA Short Form may increase the patient’s
Presence of decubitus, open wound or fistula 1
awareness of malnutrition risk [21].
Presence of trauma 1
Although patients perceive the PG-SGA as com-
prehensible and easy, PG-SGA-naive professionals
Age greater than 65 1
may perceive the professional component, especi-
Other 1 for each
condition ally the physical examination, as comprehensible
Worksheet 3 – metabolic demand (maximum 6 points) – additive but difficult [20]. Studies in the Netherlands and
Fever intensity and fever duration 0–3
Portugal have shown that improving PG-SGA
Corticosteroids type and dose 0–3
knowledge, for example by a training course, sig-
nificantly improves perceived difficulty of the
Worksheet 4 – physical examination (maximum 3 points for the
entire examination) (Fig. 1B) PG-SGA [22,23]. Training may tackle potential bar-
Muscle status 0–3 riers in performing the physical examination, but
Fat stores 0–3 may also ensure reliability. In an Australian study
Fluid status 0–3
in 189 adult inpatients, 16 dietitians trained in
use of the PG-SGA showed good inter-rater reliabi-
a
To determine score, use 1-month weight data if available. Use 6-month data, lity (intraclass correlation coefficient ¼ 0.901;
only if there is no 1-month weight data. P < 0.001) [24].

1363-1950 Copyright ß 2017 The Author(s). Published by Wolters Kluwer Health, Inc. www.co-clinicalnutrition.com 327
Assessment of nutritional metabolic status

GLOBAL USE: IMPORTANCE OF Financial support and sponsorship

TRANSLATION AND CULTURAL None.
ADAPTATION
Conflicts of interest
With PG-SGA use internationally, there is a critical
need for high-quality and linguistically validated H.J.W. is co-developer of the PG-SGA based Pt-Global
translations of the PG-SGA. A high-quality trans- app. F.D.O. is President of Ottery & Associates LLC,
lation of the PG-SGA can be defined as a translation copyright holder of the Patient-Generated Subjective
that has maintained conceptual, semantic and oper- Global Assessment (PG-SGA), co-owner and co-developer
ational equivalence to the original English PG-SGA. of the PG-SGA based Pt-Global app.
Since 2014, all new PG-SGA language versions are
developed following a ‘translation and cultural REFERENCES AND RECOMMENDED
adaptation process’, based on the Principles of Good READING
Papers of particular interest, published within the annual period of review, have
Practice for the Translation and Cultural Adaptation been highlighted as:
Process for PRO Measures (ISPOR). The Dutch [20] & of special interest
&& of outstanding interest

and Portuguese [25] PG-SGA are the first two ver-

sions of the PG-SGA that have been developed 1. Arends J, Bachmann P, Baracos V, et al. ESPEN guidelines on nutrition in
cancer patients. Clin Nutr 2017; 36:11–48.
according to the ISPOR Principles and are available 2. Cederholm T, Barazzoni R, Austin P, et al. ESPEN guidelines on definitions
for download (www.pt-global.org). Multiple official and terminology of clinical nutrition. Clin Nutr 2017; 36:49–64.
3. Vogel J, Beijer S, Delsink P et al. Guideline general and tumour specific
new PG-SGA translations will become available, for nutritional and dietary treatment. version 3.0. Available from: http://www.
example Brazilian, Danish, French, German, Italian, oncoline.nl/index.php?pagina=/richtlijn/item/pagina.php&id=40168&richtlijn_
id=1017. Accessed 23 May, 2017.
Japanese, Norwegian, Persian, Polish, Swedish and 4. Talwar B, Donnelly R, Skelly R, Donaldson M. Nutritional management in head
Thai. and neck cancer: United Kingdom National Multidisciplinary Guidelines.
J Laryngol Otol 2016; 130 (S2):S32–S40.
The availability of multiple high-quality lang- 5. Ottery FD. Definition of standardized nutritional assessment and interventional
uage PG-SGA versions has numerous implications pathways in oncology. Nutrition 1996; 12 (1 Suppl):S15–S19.
6. Langer CJ, Hoffman JP, Ottery FD. Clinical significance of weight loss in
for both clinical practice and the research setting. cancer patients: rationale for the use of anabolic agents in the treatment of
For example, in addition to its use on the local level, cancer-related cachexia. Nutrition 2001; 17 (1 Suppl):S1–20.
7. Rodrigues CS, Lacerda MS, Chaves GV. Patient Generated Subjective
availability of the PG-SGA across the globe also ena- && Global Assessment as a prognosis tool in women with gynecologic cancer.
bles the inclusion of the PG-SGA in international Nutrition 2015; 31:1372–1378.
This study in women diagnosed with gynecologic tumors demonstrated that the
multicenter studies, facilitating meta-analysis and PG-SGA can be considered not just as an indicator of nutritional risk, but also as a
benchmarking across countries. major predictor of prognosis and mortality. The PG-SGA defines at least 9 points
as cutoff for critical need for clinical intervention. Interestingly, this study demon-
strated that individuals with a score above the cutoff of 10 points were 30.7 times
more likely (95%CI: 11.8–79.4) to die within 1 year. This is impact of nutritional
CONCLUSION status on survival was independent of cancer site or stage.
8. Guerra RS, Sousa AS, Fonseca I, et al. Comparative analysis of undernutrition
The scored PG-SGA (including the PG-SGA Short & screening and diagnostic tools as predictors of hospitalisation costs. J Hum
Form) is used internationally as the reference Nutr Diet 2016; 29:165–173.
This study in a university hospital (n ¼ 637) demonstrated that severe under-
method for proactive risk assessment (screening), nutrition at hospital admission, as identified by PG-SGA, is a predictor of
assessment, monitoring and triaging for interven- hospitalization costs, increasing costs with 27.5%.
9. Hsieh MC, Wang SH, Chuah SK, et al. A prognostic model using inflammation-
tions in patients with cancer. Studies have consist- and nutrition-based scores in patients with metastatic gastric adenocarcinoma
ently confirmed high sensitivity and specificity and treated with chemotherapy. Medicine (Baltimore) 2016; 95:e3504.
10. Barata AT, Santos C, Cravo M, et al. Handgrip dynamometry and Patient-
the ability to predict both adverse and improved Generated Subjective Global Assessment in patients with nonresectable lung
clinical outcomes. Importantly, as the majority cancer. Nutr Cancer 2017; 69:154–158.
11. Härter J, Orlandi SP, Gonzalez MC. Nutritional and functional factors as pro-
input is patient-generated, the use of the PG-SGA gnostic of surgical cancer patients. Support Care Cancer 2017; Epub ahead
can streamline clinic work flow and improve the of print.
12. Kim HS, Lee JY, Lim SH, et al. Patient-Generated Subjective Global Assess-
quality of interaction between the clinician and ment as a prognosis tool in patients with multiple myeloma. Nutrition 2017;
the patient. 36:67–71.
13. El-Ghammaz AMS, Ben Matoug R, Elzimaity M, Mostafa N. Nutritional status
of allogeneic hematopoietic stem cell transplantation recipients: influencing
Acknowledgements risk factors and impact on survival. Support Care Cancer 2017; Apr 24.
doi: 10.1007/s00520-017-3716-6. Epub ahead of print.
We would like to thank Suzanne Kasenic, RD, CSO, 14. Lee HO, Han SR, Choi SI, et al. Effects of intensive nutrition education on
LDN, Susan P. DeBolt, PhD, RD and Martine Sealy, RD, nutritional status and quality of life among postgastrectomy patients. Ann Surg
Treat Res 2016; 90:79–88.
MSc, for critically reviewing the article. In addition, we 15. Sealy MJ, Nijholt W, Stuiver MM, et al. Content validity across methods of
would like to thank Suzanne and Susan for their critical & malnutrition assessment in patients with cancer is limited. J Clin Epidemiol
2016; 76:125–136.
role in the development of the PG-SGA. We would also As the first systematic review providing an overview of the methods used for
like to thank the ongoing global volunteer PG-SGA assessing malnutrition in adult cancer patients, it demonstrated that the PG-SGA
was among the four out of 37 instruments best covering the breadth of the
research network, initiated in the 1990s, for their definitions and classified with the highest content validity. It also demonstrated that
ongoing commitment and dedication to improving content validity of the methods identified was variable and below the predefined
cutoff for acceptability, when compared with a construct based on ESPEN and
patient care. ASPEN conceptual definitions.

328 www.co-clinicalnutrition.com Volume 20  Number 5  September 2017

 Role of PG-SGA in cancer Jager-Wittenaar and Ottery

16. Pinho JP, Ottery FD, Pinto P, et al. Agreement between Patient-Generated 21. Jager-Wittenaar H, Ottery FD, de Bats H, et al. Does completing the
Subjective Global Assessment (PG-SGA) and Mini Nutritional Assessment PG-SGA Short Form improve patient awareness regarding malnutrition
(MNA) in long-stay nursing home residents. Clin Nutr 2016; 35 (S1): S108. risk in patients with head and neck cancer? Clin Nutr 2016; 35 (S1):
17. Abbott J, Teleni L, McKavanagh D, et al. Patient-Generated Subjective Global S104.
Assessment Short Form (PG-SGA SF) is a valid screening tool in chemo- 22. Sealy MJ, Ottery F, Roodenburg J, et al. Dutch Patient-Generated Subjective
therapy outpatients. Support Care Cancer 2016; 24:3883–3887. Global Assessment (PG-SGA): training improves scores for comprehensi-
18. Jager-Wittenaar H, Ottery FD, de Bats H, et al. Diagnostic accuracy of bility and difficulty. Clin Nutr 2015; 34 (S1):S101.
PG-SGA SF, MUST and SNAQ in patients with head and neck cancer. Clin 23. Pinto P, Pinho JP, Vigário A, et al. Does training improve perceived compre-
Nutr 2016; 35 (S1):S103–S104. hensibility, difficulty and content validity of the Portuguese scored PG-SGA?
19. Cederholm T, Jensen GL. To create a consensus on malnutrition diagnostic Clin Nutr 2016; 35 (S1):S247–S248.
criteria: a report from the Global Leadership Initiative on Malnutrition (GLIM) 24. Kellett J, Kyle G, Itsiopoulos C, et al. Malnutrition: the importance of identifica-
meeting at the ESPEN Congress 2016. Clin Nutr 2017; 36:7–10. tion, documentation, and coding in the acute care setting. J Nutr Metab 2016;
20. Sealy MJ, Haß U, Ottery FD, et al. Translation and cultural adaptation of the 2016:9026098.
scored Patient-Generated Subjective Global Assessment (PG-SGA): an 25. Silva SCG, Pinho JP. Cross-cultural adaptation and validation of the Portu-
interdisciplinary nutritional instrument appropriate for Dutch cancer patients. guese version of the scored Patient-Generated Subjective Global Assess-
Cancer Nurs 2017; in press. ment (PG-SGA). Clin Nutr 2015; 34 (S1):S194–S195.

1363-1950 Copyright ß 2017 The Author(s). Published by Wolters Kluwer Health, Inc. www.co-clinicalnutrition.com 329