ReviewClinically relevant determinants of body composition, function and nutritional status as mortality predictors in lung cancer patients
Introduction
Many serious illnesses (e.g. cancer, sepsis or AIDS) are associated with a severe metabolic syndrome called cachexia. The important clinical symptoms include involuntary weight loss accompanied by sarcopenia (skeletal muscle wasting and weakness), fatigue, anorexia, metabolic imbalance and signs of systemic inflammation. Cachexia cannot be fully reversed by conventional nutrition support [1].
In recent years, the staging of cachexia has occurred. An international panel of experts have created a three-stage classification specific for cancer cachexia: precachexia, cachexia and refractory cachexia. Precachexia is a state characterized by early clinical signs and metabolic disturbances preceding substantial weight loss. The criteria for cachexia are considerable body weight loss (more than 5% over the past 6 months) or a body mass index (BMI) of less than 20 in combination with weight loss (more than 2% over the past 6 months) or sarcopenia (appendicular skeletal muscle index determined by dual energy X-ray absorptiometry of lower than 7.26 and 5.45 kg m−2 in men and women, respectively) in combination with body weight loss (more than 2% over the past 6 months), but have not entered the refractory stage. Refractory cachexia is a stage characterized by low performance status and low life expectancy (less than 3 months) due to very advanced or rapidly progressive cancer that is unresponsive to therapy [2], [3].
Lung cancer belongs to the type of tumors with a relatively high frequency of malnutrition, sarcopenia and cachexia, as demonstrated by the result of recent works. According to the Mini Nutrition Assessment (MNA), 26% of patients with advanced non-small cell lung carcinoma (NSCLC) were malnourished and another 46% of patients were at risk of malnutrition [4]; according to Subjective Global Assessment (SGA), 60% of patients were malnourished [5]. Prado et al. demonstrated that the majority of overweight NSCLC patients (more than 53%) were sarcopenic [6]. According to cancer-specific cachexia classifications (as mentioned above), 18% of NSCLC patients were diagnosed as cachectic, 23% of patients were diagnosed as in a state of precachexia [7].
Cachexia and muscle wasting are related to the impairment of physical function [8], quality of life [5], resistance to therapy [9] and shorter survival rate [10]. Early identification, monitoring, prevention and treatment of these nutritional deficiencies could lead to improved outcomes in the quality of life, physical performance and survival of patients with NSCLC. There are several inexpensive and accessible methods of evaluating changes in body composition, physical function and nutritional status including anthropometry, handgrip dynamometry, bioelectrical impedance analysis derived phase angle and nutritional screening questionnaires. The aim of this article is to summarize the recent knowledge of the use of these methods, their predictability of patient outcomes and the association of other clinically relevant parameters, specifically with lung cancer patients. Such an article collectively describing their practical application in clinical practice is lacking.
Section snippets
Basic anthropometric parameters
For a relatively long time weight loss has been known as an important prognostic factor in lung cancer patients [11], [12]. Perhaps the first work of trying to determine the prognostic value of basic anthropometric parameters like triceps skinfold thickness (TST), arm and wrist circumference and their association with clinical and biochemical parameters in NSCLC patients were the study of Ferrigno and Buccheri [13]. The statistical analysis proved an association of all three determined
Handgrip dynamometry
From a variety of methods to assess muscle strength, handgrip dynamometry has been shown to be a reliable and valid method, with benefits as being simple, fast performance and inexpensive. There is also growing evidence that handgrip strength is associated with nutritional and functional status, body composition, inflammation and predicts the survival rate of both healthy persons and persons with several clinical conditions like elderly persons, chronic inflammation and cancer [8], [23], [24].
Bioelectrical impedance analysis derived phase angle
Bioelectrical impedance analysis (BIA) is a method that has been used for more than 20 years to estimate body composition, both in healthy persons and in a variety of patient populations including cancer patients [31], [32]. BIA is based upon a conductance of an alternate electrical current through body fluids. Whole-body impedance is a combination of resistance (opposition offered by the body to the flow of an alternate electrical current, primarily related to the amount of water present in
Nutritional screening questionnaires
To screen and assess malnutrition, several nutritional screening questionnaires combining objective and subjective parameters were developed e.g. the SGA, the Patient generated SGA (PG-SGA), MNA or Nutritional risk screening 2002 [44], [45], [46].
Summary
This article illustrates the clinical relevance of methods like anthropometry, handgrip dynamometry, bioelectrical impedance analysis derived phase angle and nutritional screening questionnaires to predict the outcome of lung cancer patients based on the results of many recent works. These methods should undergo further research which could improve their further use in clinical practice.
Conflict of interest statement
The authors declare that they have no conflict of interest.
Acknowledgements
The authors are grateful to Lucie Vitkova for language correction. The work was supported by MH CZ–DRO (UHHK, 00179906), PRVOUK P40 and UNCE 204026/2012.
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