Clinical-Bladder cancer
Prognostic significance of the controlling nutritional status (CONUT) score in advanced urothelial carcinoma patients

https://doi.org/10.1016/j.urolonc.2019.10.014Get rights and content

Highlights

  • CONUT score is an objective tool for nutritional assessment.

  • CONUT score indicates a general condition from the aspect of nutritional status.

  • Higher CONUT score was an adverse prognosticator in advanced urothelial cancer patients.

  • CONUT score was independent of performance status as a prognosticator.

Abstract

Introduction & Objectives

The controlling nutritional status (CONUT) score, consisting of serum albumin, total lymphocyte count, and total cholesterol, is a validated and objective tool for nutritional assessment. Cancer-bearing patients often suffer from malnutrition in association with cachexia. We explored the prognostic role of malnutrition evaluated by the CONUT score in advanced urothelial carcinoma (aUC) patients.

Materials & Methods

Between 2003 and 2018, 201 aUC patients with cT4 and/or metastases to lymph nodes/distant organs were treated at a single cancer center. Of these, 185 were subjects of this retrospective study, with 16 excluded due to missing data. Clinical variables examined included age, sex, performance status (PS), body mass index (BMI), primary tumor site, lymph node/visceral metastasis, treatments before and after the diagnosis of aUC, hemoglobin, lactate dehydrogenase, alkaline phosphatase (ALP), C-reactive protein (CRP) and the CONUT score. Associations between clinical variables and overall survival (OS) were examined using the Cox proportional hazards model.

Results

The median (range) CONUT score was 2 (0–8). A higher CONUT score was associated with poorer PS (P < 0.001), lower BMI (P = 0.007), lower hemoglobin (P < 0.001), higher ALP (P = 0.005), and higher CRP (P < 0.001). During follow-up (median 12.3 months), 133 (72%) patients died. The median OS periods for patients with CONUT scores of 0 to 1, 2 to 3 and ≥4 were 19.3, 13.3, and 7.7 months, respectively (P < 0.001). Multivariate analysis revealed a higher CONUT score to be an independent and significant adverse prognostic factor (2–3 vs. 0–1, hazard ratio [HR] 1.57, P = 0.024; ≥4 vs 0–1, HR 2.94, P < 0.001), along with greater age (P = 0.003), poorer PS (P = 0.006), lower BMI (P = 0.008), primary tumor site in the upper tract (P = 0.004), higher CRP (P < 0.001), no usage of pembrolizumab (P = 0.005), and no curative treatment after the diagnosis of aUC (P = 0.035).

Conclusion

This study showed the prognostic significance of the CONUT score in aUC patients. The CONUT score indicates a patient's general condition from the aspect of nutritional status, and appears to be independent of PS as a prognosticator.

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.

Section snippets

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

References (33)

  • R Chow et al.

    Inter-rater reliability in performance status assessment among health care professionals: a systematic review

    Ann Palliat Med

    (2016)
  • AS Detsky et al.

    What is subjective global assessment of nutritional status? 1987. Classical article

    Nutr Hosp

    (2008)
  • Y Hamada

    Objective Data Assessment (ODA) methods as nutritional assessment tools

    J Med Invest

    (2015)
  • J Ignacio de Ulibarri et al.

    CONUT: a tool for controlling nutritional status. First validation in a hospital population

    Nutr Hosp

    (2005)
  • T Toyokawa et al.

    The pretreatment Controlling Nutritional Status (CONUT) score is an independent prognostic factor in patients with resectable thoracic esophageal squamous cell carcinoma: results from a retrospective study

    BMC Cancer

    (2016)
  • Y Iseki et al.

    Impact of the preoperative controlling nutritional status (CONUT) score on the survival after curative surgery for colorectal cancer

    PLoS One

    (2015)
  • Cited by (0)

    View full text