Urologic Oncology: Seminars and Original Investigations
Clinical-Bladder cancerPrognostic significance of the controlling nutritional status (CONUT) score in advanced urothelial carcinoma patients
Introduction
Urothelial carcinoma (UC), mostly comprising bladder cancer and upper tract urinary cancer (UTUC), was estimated to account for 85,000 new cases and 18,000 deaths in the United States in 2018 [1]. Although nonmetastatic and localized UC patients are subjects for curative treatment such as transurethral resection, radical cystectomy, and radical nephroureterectomy with or without perioperative chemotherapy, systemic chemotherapy has been the mainstay of treatment in advanced UC (aUC) patients. However, aUC patients have a poor prognosis, with a median overall survival (OS) of 13 to 16 months despite receiving systemic chemotherapy [2]. Recently, immune checkpoint inhibitors (ICI) have been introduced, and are reported to prolong the median OS by 3 months in aUC patients [3]. However, the long-term outcomes of ICI are unclear in the real-world practice.
Assessment of the general conditions of cancer-bearing patients is crucial for therapeutic decision-making and prognosis. The most common parameter used to assess a patient's general conditions is performance status (PS), which greatly impacts the prognosis of aUC patients [4], [5], [6]. Although PS is an established prognostic factor for aUC patients, assessment of PS is subjective and potentially carries poor interobserver agreement [7]. An objective assessment system for patients’ general condition is desirable.
Nutritional status is an indicator of general condition and is often compromised by cancer cachexia in advanced cancer patients. Methods to evaluate nutritional status are classified into 2 major categories: subjective global assessment and objective data assessment [8, 9]. Subjective global assessment involves taking a medical history and physical examinations including loss of triceps subcutaneous fat and muscle wasting of the quadriceps, ankle and sacral edema, which are complicated and require expert knowledge for accurate measurement [8]. In contrast, the controlling nutritional status (CONUT) score is a simple and validated objective data assessment system consisting of serum albumin, total lymphocyte count, and total cholesterol concentration [10]. Previous studies have demonstrated the prognostic role of malnutrition evaluated by the CONUT score in patients with several cancer types, including esophageal carcinoma, colorectal carcinoma, gastric carcinoma, lung squamous cell carcinoma, hepatocellular carcinoma and renal cell carcinoma [11], [12], [13], [14], [15], [16]. However, no study to date has investigated the prognostic impact of the CONUT score in aUC patients.
We therefore retrospectively assessed the prognostic role of the CONUT score in aUC patients who were not subjects of upfront curative surgery due to cT4 or distant or nodal metastatic diseases.
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Patients
Our Institutional Ethical Committee approved the present retrospective study protocol. A total of 201 consecutive aUC patients (inoperable cT4 and/or metastasis to lymph nodes/distant organs) treated at a single cancer center between 2003 and 2018 were enrolled in the study. Of the 201 patients, 16 patients were excluded due to missing data required for the CONUT score (12 patients without total cholesterol concentration and 4 patients without total lymphocyte count). Ultimately, data on 185
Patient characteristics
The demographics of the 185 patients are shown in Table 2. The median (range) age was 70 (38–92) years, and 125 (68%) patients were male. The primary sites of aUC were the bladder in 104 (56%) patients and the upper urinary tract in 81 (44%) patients. Of the 185 patients, 63 (34%) patients developed aUC after curative treatment for their primary diseases; 56 (30%) patients had undergone curative surgery and the other 7 (4%) patients had received definitive chemoradiotherapy. At the time of
Discussion
The present study demonstrated the prognostic significance of the CONUT score in aUC patients for the first time. A higher CONUT score was significantly and independently associated with shorter OS along with established prognostic factors including advanced age, poorer PS, lower BMI, and higher CRP. These results suggest the clinical relevance of malnutrition evaluated by CONUT as a prognostic factor in aUC patients. Considering its simplicity, objectivity, global availability and validity in
Conclusion
The present study demonstrated the prognostic significance of the CONUT score in aUC patients. Validation of multicentric larger patient cohorts is needed to confirm this finding. Since the CONUT score reflects malnutrition in the process of developing cachexia, a multimodal approach to improve cancer-induced malnutrition may improve the prognosis of aUC patients.
Conflict of interest
None
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