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Accepted Manuscript

Nutritional risk and malnutrition rates at diagnosis of cancer in

patients treated in outpatient settings. Early intervention protocol✯

Elena Álvaro Sanz (EAS) , Marga Garrido Siles (MGS) PharmD ,

Laura Rey Fernández (LRF) , Rosa Villatoro Roldán (RVT) PhD ,
Antonio Rueda Domı́nguez (ARD) PhD , Jimena Abilés. (JA)

PII: S0899-9007(18)30489-1
DOI: 10.1016/j.nut.2018.05.021
Reference: NUT 10231

To appear in: The End-to-end Journal

Received date: 19 January 2018

Revised date: 13 April 2018
Accepted date: 29 May 2018

Please cite this article as: Elena Álvaro Sanz (EAS) , Marga Garrido Siles (MGS) PharmD ,
Laura Rey Fernández (LRF) , Rosa Villatoro Roldán (RVT) PhD , Antonio Rueda Domı́nguez (ARD) PhD ,
Jimena Abilés. (JA) , Nutritional risk and malnutrition rates at diagnosis of cancer in patients
treated in outpatient settings. Early intervention protocol✯ , The End-to-end Journal (2018), doi:
10.1016/j.nut.2018.05.021

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 ACCEPTED MANUSCRIPT

Title: Nutritional risk and malnutrition rates at diagnosis of cancer in patients

treated in outpatient settings. Early intervention protocol.

Short title: Nutritional risk in oncology patients.

Authors:

1. (EAS) Elena Álvaro Sanz. Hospital Pharmacy Specialist, Pharmacy and

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Nutrition Service, Costa del Sol Hospital, Marbella (Málaga), Spain.

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[email protected]

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2. (MGS) Marga Garrido Siles. PharmD, PhD. Hospital Pharmacy Specialist,

Pharmacy and Nutrition Service, Costa del Sol Hospital, Marbella (Málaga),

Spain. [email protected] US
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3. (LRF) Laura Rey Fernández. Nutritionist. Pharmacy and Nutrition Service,

Costa del Sol Hospital, Marbella (Málaga), Spain.

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4. (RVT) Rosa Villatoro Roldán, PhD, MD. Oncologist. Oncology service, Costa

del Sol Hospital, Marbella (Málaga), Spain

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5. (ARD) *Antonio Rueda Domínguez, PhD, MD. Oncologist. Oncology service,

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Costa del Sol Hospital, Marbella (Málaga), Spain.

6. (JA)* Jimena Abilés. Nutritionist, PhD. Pharmacy and Nutrition Service, Costa
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del Sol Hospital, Marbella (Málaga), Spain. [email protected]

* These two authors have contributed equally to the manuscript as senior

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authors.
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Corresponding author: Margarita Garrido Siles

Address1: A7, km. 187. Área de Farmacia y Nutrición. Hospital Costa del Sol, 29603

Marbella (Málaga), Spain

Address2: Pº Limonar, 2, Bq3, 5ºA (Málaga), Spain.

Tel: 0034 649911480

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Tel2: 0034 951976882

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Fax: 0034 951976882

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E-mail: [email protected]

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Disclaimers: Having read the procedure for submissions, the authors declare there
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is no conflict of interest.
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ABSTRACT:
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Introduction: Malnutrition is frequent in cancer patients and is associated with a

greater rate of morbidity and mortality. However, a significant number of patients at
nutritional risk remain undetected due to the lack of a routine screening procedure
during diagnosis. Our institution has implemented a protocol for outpatients with
cancer aimed at identifying and treating malnutrition at an early stage. The main
objectives of this policy were to determine the prevalence of nutritional risk and the

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rate of malnutrition when cancer is diagnosed.

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Materials and method: For patients with cancer of upper digestive tract

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(oesophagus, stomach, pancreas or biliary tract) or head and neck cancer a complete
assessment of nutritional status was made. For patients with other solid tumours a
screening for nutritional risk was performed using the Nutriscore tool at the first
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oncology consultation. When nutritional risk was detected a complete nutritional
assessment was completed.
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Results: Of 295 consecutive patients, 21.4% were found to be at nutritional risk

(Nutriscore≥5). After complete assessment a moderate degree of malnutrition was
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observed in 76% and severe malnutrition in 12%. Among patients with colorectal
cancer or tumours of gynaecological origin, only 7.5% presented nutritional risk, but
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more than half (52.8%) presented cachexia.

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Conclusion: The high rate of malnutrition observed and the identification of

cachexia at an early stage highlight the importance of obtaining early identification
of patients at risk, in order to improve the efficacy of nutritional interventions.
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KEY WORDS: Nutritional screening, cancer, oncology outpatients, malnutrition,

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Nutriscore, Protocol.
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Introduction
Cancer patients form a heterogeneous group, in which the prevalence of
malnutrition is very significant, ranging from 20-80%, depending on the location of
the tumour, the patient’s age and the stage of the disease. In this respect, patients

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with gastrointestinal tract, head or neck cancers are at especially high risk (1-4).

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Many factors may contribute to the deterioration of nutritional status in cancer
patients, including mechanical, functional or metabolic disorders related to the

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neoplastic process, side effects of the surgery, chemotherapy, radiotherapy or
immunotherapy, patient-related questions (physical deterioration, personal habits,

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psychological aspects, etc.), issues regarding healthcare personnel (absence of
nutritional assessment, lack of knowledge and/or training to detect malnutrition,
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delay in initiating adequate nutritional treatment, etc.), or aspects related to the
healthcare authorities (such as the lack of multidisciplinary care units) (5).

The patient’s nutritional status can influence the oncological process, and studies
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have reported an association between malnutrition and increased postoperative

complications (6,7), greater toxicity of treatments (8,9), a poorer response to
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antineoplastic therapy and greater risk of mortality (6), worse quality of life (10)
and increased duration of hospital stay and higher associated costs (11).
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Among the different prognostic factors in cancer patients (type of tumour, stage of
the disease, etc.), weight loss is potentially sensitive to therapeutic intervention. In
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this respect, the guidelines of the European Society for Clinical Nutrition and
Metabolism (ESPEN) recommend nutritional assessment for all cancer patients at
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the moment of diagnosis, and in situations of risk, the performance of a complete

nutritional assessment to facilitate diagnosis and the provision of appropriate
nutritional support according to the patient’s requirements and clinical condition
(12).
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However, despite the impact of malnutrition and the importance of early

intervention in the clinical evolution of cancer patients, the lack of a routine
screening procedure during diagnosis means that a significant number of patients at
nutritional risk remain undetected and therefore that the possibility of an early
intervention, which a priori would be more effective, is lost. This unsatisfactory
situation persists despite the regular monitoring and follow up of cancer patients by

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healthcare personnel (13). In this respect, Hebeturne et al. (14) reported that only

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30-60% of cancer patients who were at risk of malnutrition received nutritional
treatment. Indeed, on many occasions even patients diagnosed with severe

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malnutrition fail to receive an appropriate nutritional intervention (3, 15).

Our hospital has defined and implemented a nutritional protocol for patients with

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cancer, to be applied after diagnosis but before the planned treatment is
implemented, aimed at identifying and treating malnutrition at an early stage. The
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long-term objectives of this policy are to determine the prevalence of nutritional
risk, to evaluate the capability of Nutriscore, a new validated screening method in
oncological patients, and thus to identify nutritional risk at diagnosis. The main aim
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of this study is to assess the rate of malnutrition when cancer is diagnosed, in order
to determine its association with certain variables related to the tumour and to the
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patient.
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Materials and methods

Study population
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Adult patients (aged ≥18 years) diagnosed with solid tumours for whom
chemotherapy was started between April 2016 and June 2017 were eligible for
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inclusion in the study. The patients presented different stages of cancer, from early
diagnosis to advanced stages. Patients were excluded if they had previously
received chemotherapy or were unable to understand the purpose of the study. The
study protocol was carried out according to the guidelines established by the
Declaration of Helsinki and was approved by the Local Ethics Committee for Clinical
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Research. All study patients granted their informed consent in writing to participate
in the study.

Study design
A working group was set up, including oncologists, specialists in oncology pharmacy
and nutritionists, to devise an early approach protocol for cancer patients with
malnutrition, following diagnosis of the neoplastic process. The protocol defines two

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levels of action, depending on the location of the tumour.

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Group 1: Patients with localised cancer in the upper digestive tract (oesophagus,

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stomach, pancreas or biliary tract) or cancerous tumours of the head or neck. These
patients are referred directly for nutritional consultation, either by the
corresponding oncology committee or during the hospital procedure in which the

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tumour pathology was diagnosed. The nutritional consultation consists of a
screening (performed by the nutritionist), a complete assessment of nutritional
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status and a nutritional diagnosis, before reaching a decision regarding the most
appropriate treatment for the patient’s requirements and characteristics.
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Group 2: Patients with solid tumours not included in the above category. In this
group, the screening for nutritional risk is performed at the first consultation with
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the oncologist by the doctor or at the outpatient pharmacy consultation by the

specialist pharmacist, and in any case before chemotherapy is initiated. When a risk
of malnutrition is identified, nutritional status is assessed and the procedure shown
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in Fig. 1 is followed.
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During monitoring and follow up, the patient’s weight is determined on day 1 of
each cycle of chemotherapy, together with an assessment of adherence and
tolerance to the oral supplementation prescribed. The patient is referred to the
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nutritionist if weight loss or poor tolerance to the nutritional treatment is observed.

In addition, all patients in group 1 are invited to a nutritional consultation on
completion of every two cycles of chemotherapy.

Patients at nutritional risk were identified using Nutriscore (16), a nutritional

screening test for outpatients with cancer, which takes into account involuntary
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weight loss in the last three months, decreased appetite, tumour location and
oncology treatment. Patients are considered at risk when the Nutriscore obtained is
≥5 points (9 points is the maximum score). Nutriscore is a screening method that
has been validated in the Spanish population by reference to the Patient-Generated
Subjective Global Assessment (PG-SGA) and the Malnutrition Score Tool (MST), with
a sensitivity of 97.3% and a specificity of 95.9%. The Nutritional Risk Screening

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(NRS02) was used for hospitalised patients, in accordance with the standard

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protocol at the hospital.

The PG-SGA was used to evaluate the patients’ nutritional status (17). This

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instrument measures weight loss, incorporates the patient’s clinical history
(diagnosis, current treatment, medication and analytical results), includes a physical

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examination and, moreover, involves the patients themselves, who are asked to
provide information regarding their symptoms, the type of diet followed and their
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daily activity. PG-SGA classifies patients as: a) well nourished; b) at nutritional risk
or moderately malnourished; or c) severely malnourished. PG-SGA is carried out at
the nutrition consultation (for the patients in Group 1) or in the oncology pharmacy
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consultation, in both cases by personnel trained to carry out the evaluation.

In all cases, the presence or absence of cachexia was evaluated at the outset,
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following the definition proposed by Fearon et al.: weight loss >5% during the
previous six months (in the absence of simple undernourishment); or BMI <20
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Kg/m2 and any degree of weight loss >2% or appendicular skeletal muscle index
consistent with sarcopenia (males <7.26Kg/m2, females <5.45kg/m2) and any
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degree of weight loss >2% (18). In addition, markers of inflammation and their
possible relationship with nutritional risk were determined using the Glasgow
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Prognostic Score (GPS) and the Inflammatory-Nutritional Index (INI), as systemic

inflammation-based prognostic scores (19,20,21). For this study, INI values <0.35
were considered to reflect risk of malnutrition. The cutoff points of normal values
for serum albumin and Protein C reactive (CPR) were 3.5 g/dl and 10 mg/dl,
respectively.
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In determining the implementation of nutritional measures, the time elapsed

between nutritional risk screening and the start of chemotherapy was taken into
account.

Statistical methods
A descriptive analysis was performed using mean and standard deviation values
(median and interquartile range (IR) for samples with fewer than 30 patients per

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subgroup) for the quantitative variables, and the frequency distribution for

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qualitative variables. The differences in the presence of nutritional risk were
evaluated by the Student t test for quantitative variables (Mann-Whitney U test

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when distribution was non-normal), and the chi-square test for qualitative
variables. Finally, a multivariate logistic regression model was obtained, taking the

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presence of nutritional risk as the outcome variable. The level of statistical
significance was set at p<0.05.
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Results
In total, 295 patients, with a mean age of 61 ±11 years, took part in the study. Of
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these patients, 24.7% were aged 70 years or more. The most prevalent tumours in
our sample corresponded to breast, lung and colorectal cancer. The clinical features
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and characteristics of the patients are shown in Table 1.

All patients were given nutritional screening, and 21.4% were found to be at
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nutritional risk (Nutriscore ≥5). By type of tumour, the patients with oesophagus-
gastric and pancreas-bile duct neoplasms were at highest nutritional risk, at
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diagnosis (Table 2).

At diagnosis, 58.3% of the patients had suffered weight loss in the previous three
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months, although the median weight loss value when nutritional screening was
performed was only 3% (IR=8.8%). In 63.2% of the patients, the weight loss was
≤10% and in 36.8% it was >10%. In patients with pancreas-bile duct or oesophagus-
gastric tumours, nearly 100% had experienced weight loss, meaning that virtually
all patients with this kind of tumour are at risk of malnutrition at diagnosis. The
average weight loss among these patients is about 10%.
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Among patients with colorectal cancer or tumours of gynaecological origin, only

7.5% presented nutritional risk, but screening revealed that 75.5% had experienced
weight loss and more than half presented cachexia. In all the subgroups of patients,
the median BMI was within the normal range, with a mean value of 26.6 ± 4.9
kg/m2. With regard to the inflammatory markers-based index, the highest
proportion of patients with INI risk were those with tumours of the lung, pancreas,

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head or neck, or colorectal cancer. Only the patients with pancreatic cancer

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presented an association between INI risk and the presence of nutritional risk
according to Nutriscore (Table 2).

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The patients at risk of malnutrition were mostly male, with a primary tumour
located in the upper digestive tract or head and neck and being treated with

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palliative chemotherapy. These patients were more likely to present cachexia and
recorded higher values for ECOG performance status, GPS and INI risk. Regarding
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age, no significant differences were found. The corresponding data are shown in
Table 3.

An assessment of nutritional status (PG-SGA) was performed for 95% of the patients
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considered to be at nutritional risk. A moderate degree of malnutrition was

observed in 76% and severe malnutrition in 12%. The remaining 12% of patients
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presented good nutritional status at the time of assessment.

With respect to the time elapsed between nutritional risk screening and the start of
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treatment, 27% of patients were screened at least one week before the first cycle of
chemotherapy. On average, this period was 31.7 ± 22.1 days for patients at greatest
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risk (those with pancreatic cancer, and oesophagus-gastric, head and neck
tumours).
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Discussion
Oncology is one of the areas of medicine where recent advances can significantly
improve outcomes for patients. Nevertheless, there are various factors that can limit
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the response to even the best therapies. Malnutrition is common, especially among
cancer patients (6,14) and is acknowledged to be an important prognostic factor (4).

The high risk of malnutrition, resulting both from the physical and metabolic effects
of the cancer and from the influence of anticancer treatment, together with its major
impact on survival rates, makes cancer patients very sensitive to strategies that may
prevent, delay or overcome malnutrition (6). Therefore, nutritional risk screening is

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performed in order to increase awareness and to facilitate early recognition and

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treatment.

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Previous recommendations and guidelines (12) have been issued for the inclusion
of nutritional management in the global approach to this disease. The main
contribution of this paper is to present the evaluation of malnutrition in a global

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population of patients with cancer and to perform a screening at the time of
diagnosis. The results that have been published in this regard show there is a high
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prevalence of malnutrition risk, reaching 31.8% among outpatients (4) and 33.9%
among hospitalised patients (11). Our own study group has recorded a prevalence
of nutritional risk of 21.4%, a value considerably lower than that published
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elsewhere (4,22,23), especially compared with the results obtained in Mexico (24),
the Czech Republic (25) and Norway (26). A possible explanation for this
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discrepancy lies in the fact that most other studies have been performed concerning
hospitalised patients, who may be in a more delicate condition than those who are
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treated in an ambulatory setting. Moreover, hospitalisation per se, regardless of the

treatment provided, is associated with a deterioration of nutritional status (27,28,
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29).

It should be noted that our study is based on mixed populations, and the inclusion of
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a large proportion of patients with breast cancer, who do not present the same
nutritional risk or degree of weight loss as patients with other types of tumours
(30), which might reduce the proportion of patients at risk, compared to the
findings of other studies. Moreover, all of these studies used the NRS02 screening
method. Although NRS02 is reported to perform well for hospitalised patients, the
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Nutriscore method was specially designed to detect the risk of malnutrition in

cancer outpatients and has been validated in the Spanish population. (16).

Although a cancer patient’s nutritional status generally worsens as the disease

progresses, and with the administration of cytotoxic treatment (31-34),
malnutrition can appear at any time during the disease, even at diagnosis (31).

In our study, 36.8% of patients experienced weight loss >10%, a value which is

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considered clinically relevant because it is associated with functional impairment

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and a worse outcome (12). This prevalence is within the range reported by Dewys,

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who found that 31-87% of cancer patients experienced weight loss before receiving
chemotherapy (36).

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In our study population, the distribution of body weight loss and the nutritional risk
was not homogeneous, and was associated with the type of primary tumour and the
treatment programme provided. Over 90% of patients with pancreas-bile duct or
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oesophagus-gastric cancer experienced weight loss, of about 10%. A Nutriscore >5,
a value suggesting the need for more extensive nutritional assessment and potential
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intervention, were recorded in about 75% of the patients with pancreas-bile duct or
oesophagus-gastric cancer. In a previous study conducted in patients with
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gastrointestinal tract cancer, 70% of the patients with tumours in the lower
intestinal tract, 78% of those with oesophageal or stomach cancer and 87% of those
with pancreatic tumours presented weight loss at diagnosis (35). According to a
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related study, about 50% of patients with pancreatic or stomach cancer were at risk
of malnutrition (4).
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Although in our population BMI values were lower in patients at risk than in those
not at risk, both groups had BMI values close to normality. We conclude, therefore,
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that BMI alone is not a sufficient indicator of nutritional status.

Clearly, the satisfactory outcome of mandatory screening depends on appropriate

action being taken in response to an abnormal screening result and on the
treatment strategies initiated being effective.
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The presence of risk does not always include the condition of malnutrition, but
refers to the risk of its developing. In fact, our results show that 12% of the patients
at nutritional risk were in fact classified as well nourished. The recorded prevalence
of malnutrition (18.5%) was below the range reported in previous research (34-
61%) for different types of tumour (1,2,6,11,14,37).

The maximum expression of malnutrition in cancer is tumour cachexia, which is

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directly or indirectly responsible for death in a third of cancer patients (38). In a

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consensus document, Fearon et al. defined this condition as a multifactorial
syndrome characterised by ongoing loss of skeletal muscle mass (with or without

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loss of fat mass) that cannot be fully reversed by conventional nutritional support
and leads to progressive functional impairment (18). Cachexia is defined as a weight

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loss >5% during six months (in the absence of simple starvation). Hence, with
chronic illness even a low rate of weight loss can give rise to cachexia. Based on this
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criterion, we found that 40% of patients had cachexia at diagnosis. Although the
previous lack of a definition and of commonly-accepted diagnostic and classification
criteria during the last decade make comparison with published data difficult, it
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should be noted that cachexia-anorexia syndrome has been described in 20-40% of

patients at diagnosis (39).
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Interestingly, in our study although there were a low proportion of patients with
colorectal cancer and nutritional risk, more than half were classified as cachectic.
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Clearly, patients with cancer might present with malnutrition (secondary to

anorexia or starvation), cachexia or both (these are two different processes). In an
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earlier study, Rosenberg (40) focused on the changes in body composition that are
characteristic of cachexia, coining the term ‘sarcopenia’ or muscle wasting. This
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condition is not restricted to individuals who appear thin or wasted. Indeed, in our
study, the patients with colorectal cancer were characterised by their heavy stature,
with a median BMI of 26.6 (RI: 4.8). Although we did not specifically measure
sarcopenia, earlier studies have reported a significant prevalence of sarcopenia in
colorectal cancer associated with treatment toxicity, poor functional status and
decreased survival (41, 42, 43, 44) which leads us to believe that this group of
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patients, although not detected in screening as being at risk, are in need of special
attention.

There is good evidence that a chronic systemic inflammatory response provokes the
cardinal features of cancer cachexia and plays an important role in its genesis and
progression. (19, 45,46). The most common measure of the systemic inflammatory
response in cancer patients is an elevated C-reactive protein concentration(18).

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Other measures that have recently been employed include systemic inflammation-

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based scores such as the GPS and the Inflammatory-Nutritional Index (INI) (47, 20).
In the present study, high GPS were observed, and most patients had an INI score

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<0.35. Several studies have found GPS to be a mortality predictor in patients with
colorectal, lung or gastric cancer and that a high GPS is associated with a linear

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reduction in survival (48, 49). Other studies have also shown that INI is an
independent predictor of survival and is associated with GPS (21).
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The use of these scores facilitates the identification of patients who have or are
likely to develop cachexia, present a poor response to treatment and are likely to
have poor survival.
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The clinical management of cachexia is currently both limited and complex. Various
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procachectic mechanisms are involved, and these should be assessed and ranked
according to importance and reversibility before a management plan is adopted (51-
56).
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While it is generally accepted that nutritional support is ineffective at advanced

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stages of the disease, recent research has shown that at earlier stages, when the
nutritional status is only marginally compromised, personalised nutritional
counselling may prove beneficial, even concerning the final oncologic outcome.
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Conclusion:

Although it has been known since the early 1980s that weight loss frequently affects
cancer patients and that it depends on the type of tumour, the stage of the disease
and the oncologic treatment received, the present study nevertheless adds new
information (36, 57). This is the first investigation to make systematic use of
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Nutriscore to define the nutritional risk of cancer outpatients. Moreover, the high
rate of malnutrition observed and the identification of cachexia at an early stage
highlight the importance of obtaining early identification of patients at risk, in order
to change the timing of interventions and improve their efficacy.

DECLARATIONS:

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Acknowledgments :
The authors thank the hospital day staff and patients for their collaboration.

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We also thank the research team at the Costa del Sol Hospital for their support.
This study was partially presented at the V National Oncology and Oncology-

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Pharmacy Congress “Tendiendo puentes” held in Toledo, Spain, in November 2017,
where it received the second prize for best study presented.
The present study is part of a Ph.D. research programme being conducted at the
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University of Málaga.
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Funding sources
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This research did not receive any specific grant from funding agencies in the public,
commercial, or not-for-profit sectors.
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Statement of Authorship
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EAS, MGS, JA, ARD, equally contributed to the conception and design of the research;
all authors contributed to the generation, collection and assembly of the data; EAS,
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MGS and JA equally contributed to the analysis and interpretation of the data and
wrote the paper. All authors read and critically revised the manuscript, and agree to
be fully accountable for ensuring the integrity and accuracy of the work. EAS, MGS,
JA and ARD approved the final version of the manuscript.
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Conflict of interest
MGS and JA have participated in a Fresenius-Kabi Advisory Board.
The authors declare there is no conflict of interest.

Ethics
The study protocol was approved by the Medical Ethics Committee of the Costa del

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Sol Hospital.

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All patients provided signed informed consent.

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Fig 1 Performance algorithm.

Oncology patients candidate to receive chemotherapy treatment.

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Group 1: Patients with localised cancer in the Group 2: Patients with solid tumours not
upper digestive tract (esophagus, stomach, included in the above category

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pancreas or biliary tract) or cancerous tumours
of the head or neck

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• Oncology committee
• First consultation with the
• During the hospital procedure
oncologist or at the outpatient
pharmacy

Nutritional consultation
(Nutritional assessment
Treatment)
US Screening for nutritional risk
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With Risk
(Nutriscore≥5) Without Risk
(Nutriscore<5)
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PG-SGA
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(B) Risk/Moderately (A) Well nourished Follow-up

malnourished
(C) Severely malnourished
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PG-SGA: Patient-Generated Subjective Global Assessment

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Table 1. Patients characteristics

N %
Overall 295
Gender
Female 158 53.6
Male 137 46.4
Age (years), median, IR 62(17)

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Site of primary tumour
Head-neck 12 4.1

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Colon-rectum 53 18.0

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Oesophagus-gastric 16 5.4
Gynaecology 35 11.9
Breast 73 24.7
Pancreas-bile ducts
Lung
Urothelial
17
64
12
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21.7
4.1
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Other 13 4.4
Treatment intention
Curative/Radical 172 58.3
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Palliative 123 41.7

GPS
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0 131 44.4
1 120 40.7
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2 15 5.1
INI-Risk 119 44.7
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Cachexia 118 40.0

BMI (mean±SD) 26.6±4.9
Nutritional Risk
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(NUTRISCORE)
≥5 63 21.4
<5 232 78.6
GPS: Glasgow Prognostic Score
INI: Inflammatory-Nutritional Index.
BMI: Body Mass Index
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Table 2. Nutritional and prognostics parameters of the study population.

Tumour % Patients Patients %Weight BMI Cachexia GPS% INI-Risk

at with loss (median, % (0/1/2) (% pnt)
nutritional Weight (median, IR)
risk loss (%) IR)
Oesophagus- 75.0 93.8 9.8(14.9) 65.5 50/43.8/6.3 31.3

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24,4(7,4)
gastric

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Pancreas-bile 70.6 94.1 10.6(7.6) 88.2 37.5/50/12.5 62.5
24,9(5,0)
ducts

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Head-neck 33.3 50 2.2(16.9) 25,1(6,5) 41.7 41.7/50/8.3 50
Gynaecology 28.6 71.4 6(11.5) 26,1(5,3) 54.3 54.8/35.5/9.7 41.9
Lung 26.6 59.4 3.9(8.8) 24,7(5,9) 42.2 19/72.4/8.6 75.9
Colon-rectum
Breast
Urothelial
7.5
0
0
75.5
21.9
66.7
5.8(9.3)
0(-2.1)
2.2(9.9)
US26,2(4,8)
26,6(8,4)
29,8(4,3)
52.8
5.5
33.3
45.1/54.9/0
88.5/9.8/1.6
36.4/63.6/0
47.1
8.2
41.7
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Other 30.8 61.5 5(14.4) 22,8(2,2) 46.2 30/50/20 70
Total 21.4 58.3 3
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BMI: Body Mass Index

GPS: Glasgow Prognostic Score
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INI: Inflammatory-Nutritional Index

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Table 3. Comparison for nutritional risk.

NO nutritional Nutritional p
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risk%(n) risk%(n)
Age
<70 years 78.4(174) 21.6(48) 0.976
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≥70 years 79.5(58) 20.5(15)

Sex
Male 73.0(100) 27.0(37) 0.039
Female 83.5(132) 16.5(26)
Grouped tumour location
Upper digestive/head and 37.8(17) 62.2(28) <0.001
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neck
All others 86.0(215) 14.0(35)
Treatment intention
Curative/Radical 86.6(149) 13.4(23) <0.001
Palliative 67.5(83) 32.5(40)
% Weight loss at diagnosis 0%±5.4 13.5%±7.1 <0.001
(median)

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GPS
0 87.8(115) 12.2(16)

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1 74.2(89) 25.8(31) <0.001
2 26.7(4) 73.3(11)

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INI-Risk 38.9(208) 65.5(58) <0.001
Cachexia
Presence of cachexia
Absence of cachexia
50.8(60)
97.2(172) US 49.2(58)
2.8(5)
<0.001
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GPS: Glasgow Prognostic Score
INI: Inflammatory-Nutritional Index
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